EX-10.12



 Exhibit 10.12 
  

			
	



	  	 ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

DIVISION OF BUSINESS AND FINANCE
  

SECTION A: CONTRACT AMENDMENT


  

							
	1. AMENDMENT #	  	2. CONTRACT #:	  	3. EFFECTIVE DATE OF AMENDMENT:	  	4. PROGRAM
				
	11	  	YH14-0001-07	  	October 1, 2015	  	DHCM - ACUTE

  

	5.	CONTRACTOR NAME AND ADDRESS: 

 Health Choice Arizona 

410 N. 44th Street, Suite 900 

Phoenix, AZ 85008 
  

	5.	PURPOSE: To renew the Contract for the period October 1, 2015 through September 30, 2016 and to amend Section B, Capitation Rates and Contractor Specific Requirements, Section C, Definitions, Section D, Acute Care
Program Requirements, Section E, Contract Terms and Conditions, and Section F, Attachments. 

  

	6.	THE ABOVE REFERENCED CONTRACT IS HEREBY AMENDED AS FOLLOWS: 

  

	 	•	 	Section B, Capitation Rates and Contractor Specific Requirements 

  

	 	•	 	Section C, Definitions 

  

	 	•	 	Section D, Acute Care Program Requirements 

  

	 	•	 	Section E, Contract Terms and Conditions 

  

	 	•	 	Section F, Attachments 

  

	 	•	 	Attachment F2, Provider Claim Dispute Standards 

  

	 	•	 	Attachment F3, Contractor Chart of Deliverables 

 Refer to the individual Contract sections for specific
changes. 
  

	7.	EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL EFFECT. 


IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT 

 

			
	9. SIGNATURE OF AUTHORIZED REPRESENTATIVE:	  	10. SIGNATURE OF AHCCCS CONTRACTING OFFICER:
		
	 /s/ Mike Uchrin
	  	 /s/ Meggan Harley

	TYPED NAME:             MIKE UCHRIN	  	TYPED NAME:             MEGGAN HARLEY
		
	TITLE:         CHIEF EXECUTIVE OFFICER	  	TITLE:         PROCUREMENT MANAGER
		
	DATE:                           9/3/15	  	DATE:                           9/3/2015








 Contract No. YH14-0001 

 
  

 
 TABLE OF CONTENTS 

 

									
	 SECTION A: CONTRACT AMENDMENT
	  	 	1	  
		
	 SECTION B: CAPITATION RATES AND CONTRACTOR SPECIFIC REQUIREMENTS
	  	 	5	  
		
	 SECTION C: DEFINITIONS
	  	 	6	  
			
		 	 PART 1. DEFINITIONS PERTAINING TO ALL AHCCCS CONTRACTS
	  	 	6	  
		 	 PART 2. DEFINITIONS PERTAINING TO ONE OR MORE AHCCCS CONTRACTS
	  	 	20	  
		
	 SECTION D: ACUTE CARE PROGRAM REQUIREMENTS
	  	 	27	  
				
		 	1.	  	PURPOSE, APPLICABILITY, AND INTRODUCTION	  	 	27	  
		 	2.	  	ELIGIBILITY CATEGORIES	  	 	28	  
		 	3.	  	ENROLLMENT AND DISENROLLMENT	  	 	29	  
		 	4.	  	ANNUAL AND OPEN ENROLLMENT CHOICE	  	 	32	  
		 	5.	  	RESERVED	  	 	32	  
		 	6.	  	AUTO-ASSIGNMENT ALGORITHM	  	 	32	  
		 	7.	  	AHCCCS MEMBER IDENTIFICATION CARDS	  	 	33	  
		 	8.	  	MAINSTREAMING OF AHCCCS MEMBERS	  	 	33	  
		 	9.	  	TRANSITION ACTIVITIES	  	 	34	  
		 	10.	  	SCOPE OF SERVICES	  	 	36	  
		 	11.	  	SPECIAL HEALTH CARE NEEDS	  	 	46	  
		 	12.	  	BEHAVIORAL HEALTH SERVICES	  	 	47	  
		 	13.	  	AHCCCS GUIDELINES, POLICIES AND MANUALS	  	 	53	  
		 	14.	  	MEDICAID SCHOOL BASED CLAIMING	  	 	53	  
		 	15.	  	PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM	  	 	53	  
		 	16.	  	STAFF REQUIREMENTS AND SUPPORT SERVICES	  	 	54	  
		 	17.	  	WRITTEN POLICIES AND PROCEDURES	  	 	59	  
		 	18.	  	MEMBER INFORMATION	  	 	59	  
		 	19.	  	SURVEYS	  	 	61	  
		 	20.	  	CULTURAL COMPETENCY	  	 	62	  
		 	21.	  	MEDICAL RECORDS	  	 	62	  
		 	22.	  	ADVANCE DIRECTIVES	  	 	63	  
		 	23.	  	QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT	  	 	63	  
		 	24.	  	MEDICAL MANAGEMENT	  	 	71	  
		 	25.	  	TELEPHONE PERFORMANCE STANDARDS	  	 	73	  
		 	26.	  	GRIEVANCE SYSTEM	  	 	73	  
		 	27.	  	NETWORK DEVELOPMENT	  	 	74	  
		 	28.	  	PROVIDER AFFILIATION TRANSMISSION	  	 	76	  
		 	29.	  	NETWORK MANAGEMENT	  	 	76	  
		 	30.	  	PRIMARY CARE PROVIDER STANDARDS	  	 	77	  
		 	31.	  	MATERNITY CARE PROVIDER STANDARDS	  	 	78	  
		 	32.	  	REFERRAL MANAGEMENT PROCEDURES AND STANDARDS	  	 	79	  
		 	33.	  	APPOINTMENT STANDARDS	  	 	79	  
		 	34.	  	FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS	  	 	81	  
		 	35.	  	PROVIDER MANUAL	  	 	81	  
		 	36.	  	PROVIDER REGISTRATION	  	 	82	  
		 	37.	  	SUBCONTRACTS	  	 	82	  
		 	38.	  	CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM	  	 	84	  
		 	39.	  	SPECIALTY CONTRACTS	  	 	88	  
		 	40.	  	HOSPITAL SUBCONTRACTING AND REIMBURSEMENT	  	 	88	  
		 	41.	  	RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT	  	 	89	  
		 	42.	  	INCENTIVES/PAY FOR PERFORMANCE	  	 	89	  
		 	43.	  	MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN	  	 	90	  


  
 Acute Care Contract 

10/01/2015 Renewal 
  

2 









 Contract No. YH14-0001 

 
  

 


									
		 	44.	  	MATERIAL CHANGE TO BUSINESS OPERATIONS	  	 	90	  
		 	45.	  	MINIMUM CAPITALIZATION	  	 	91	  
		 	46.	  	PERFORMANCE BOND OR BOND SUBSTITUTE	  	 	91	  
		 	47.	  	AMOUNT OF PERFORMANCE BOND	  	 	92	  
		 	48.	  	ACCUMULATED FUND DEFICIT	  	 	92	  
		 	49.	  	ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS	  	 	92	  
		 	50.	  	FINANCIAL VIABILITY STANDARDS	  	 	92	  
		 	51.	  	SEPARATE INCORPORATION	  	 	93	  
		 	52.	  	MERGER, ACQUISITION, REORGANIZATION, JOINT VENTURE AND CHANGE IN OWNERSHIP	  	 	93	  
		 	53.	  	COMPENSATION	  	 	94	  
		 	54.	  	PAYMENTS TO CONTRACTORS	  	 	97	  
		 	55.	  	CAPITATION ADJUSTMENTS	  	 	97	  
		 	56.	  	MEMBER BILLING AND LIABILITY FOR PAYMENT	  	 	98	  
		 	57.	  	REINSURANCE	  	 	99	  
		 	58.	  	COORDINATION OF BENEFITS AND THIRD PARTY LIABILITY	  	 	102	  
		 	59.	  	COPAYMENTS	  	 	106	  
		 	60.	  	MEDICARE SERVICES AND COST SHARING	  	 	106	  
		 	61.	  	MARKETING	  	 	106	  
		 	62.	  	CORPORATE COMPLIANCE	  	 	106	  
		 	63.	  	RECORDS RETENTION	  	 	111	  
		 	64.	  	SYSTEMS AND DATA EXCHANGE REQUIREMENTS	  	 	111	  
		 	65.	  	ENCOUNTER DATA REPORTING	  	 	114	  
		 	66.	  	ENROLLMENT AND CAPITATION TRANSACTION UPDATES	  	 	116	  
		 	67.	  	PERIODIC REPORTING REQUIREMENTS	  	 	116	  
		 	68.	  	REQUESTS FOR INFORMATION	  	 	117	  
		 	69.	  	DISSEMINATION OF INFORMATION	  	 	117	  
		 	70.	  	OPERATIONAL AND FINANCIAL READINESS REVIEWS	  	 	117	  
		 	71.	  	MONITORING AND OPERATIONAL REVIEWS	  	 	117	  
		 	72.	  	SANCTIONS	  	 	118	  
		 	73.	  	BUSINESS CONTINUITY AND RECOVERY PLAN	  	 	119	  
		 	74.	  	MEDICARE REQUIREMENTS	  	 	119	  
		 	75.	  	PENDING LEGISLATION/OTHER ISSUES	  	 	120	  
		 	76.	  	VALUE-BASED PURCHASING	  	 	122	  
		
	 SECTION E: CONTRACT TERMS AND CONDITIONS
	  	 	123	  
				
		 	1.	  	ADVERTISING AND PROMOTION OF CONTRACT	  	 	123	  
		 	2.	  	APPLICABLE LAW	  	 	123	  
		 	3.	  	ARBITRATION	  	 	123	  
		 	4.	  	ASSIGNMENT AND DELEGATION	  	 	123	  
		 	5.	  	ASSIGNMENT OF CONTRACT AND BANKRUPTCY	  	 	123	  
		 	6.	  	AUDITS AND INSPECTIONS	  	 	123	  
		 	7.	  	AUTHORITY	  	 	123	  
		 	8.	  	CHANGES	  	 	123	  
		 	9.	  	CHOICE OF FORUM	  	 	124	  
		 	10.	  	COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS	  	 	124	  
		 	11.	  	CONFIDENTIALITY AND DISCLOSURE OF CONFIDENTIAL INFORMATION	  	 	124	  
		 	12.	  	CONFLICT OF INTEREST	  	 	124	  
		 	13.	  	CONTINUATION OF PERFORMANCE THROUGH TERMINATION	  	 	125	  
		 	14.	  	CONTRACT	  	 	125	  
		 	15.	  	CONTRACT INTERPRETATION AND AMENDMENT	  	 	125	  
		 	16.	  	COOPERATION WITH OTHER CONTRACTORS	  	 	125	  
		 	17.	  	COVENANT AGAINST CONTINGENT FEES	  	 	125	  
		 	18.	  	DATA CERTIFICATION	  	 	125	  
		 	19.	  	DISPUTES	  	 	125	  
		 	20.	  	E-VERIFY REQUIREMENTS	  	 	126	  


  
 Acute Care Contract 

10/01/2015 Renewal 
  

3 









 Contract No. YH14-0001 

 
  

 


									
		 	21.	  	EFFECTIVE DATE	  	 	126	  
		 	22.	  	FEDERAL IMMIGRATION AND NATIONALITY ACT	  	 	126	  
		 	23.	  	GRATUITIES	  	 	126	  
		 	24.	  	INCORPORATION BY REFERENCE	  	 	126	  
		 	25.	  	INDEMNIFICATION	  	 	126	  
		 	26.	  	INDEMNIFICATION - PATENT AND COPYRIGHT	  	 	127	  
		 	27.	  	INSURANCE	  	 	127	  
		 	ATTACHMENT E-1	  	 	128	  
		 	28.	  	IRS W9 FORM	  	 	132	  
		 	29.	  	LOBBYING	  	 	132	  
		 	30.	  	NO GUARANTEED QUANTITIES	  	 	132	  
		 	31.	  	NON-DISCRIMINATION	  	 	132	  
		 	32.	  	NON-EXCLUSIVE REMEDIES	  	 	132	  
		 	33.	  	OFF-SHORE PERFORMANCE OF WORK PROHIBITED	  	 	132	  
		 	34.	  	ORDER OF PRECEDENCE	  	 	132	  
		 	35.	  	OWNERSHIP OF INFORMATION AND DATA	  	 	133	  
		 	36.	  	RESERVED	  	 	133	  
		 	37.	  	RELATIONSHIP OF PARTIES	  	 	133	  
		 	38.	  	RIGHT OF OFFSET	  	 	133	  
		 	39.	  	RIGHT TO ASSURANCE	  	 	133	  
		 	41.	  	RESERVED	  	 	133	  
		 	42.	  	SEVERABILITY	  	 	133	  
		 	43.	  	SUSPENSION OR DEBARMENT	  	 	134	  
		 	44.	  	TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR AND TERMINATION	  	 	134	  
		 	45.	  	TERM OF CONTRACT AND OPTION TO RENEW	  	 	135	  
		 	46.	  	TERMINATION—AVAILABILITY OF FUNDS	  	 	135	  
		 	47.	  	TERMINATION FOR CONFLICT OF INTEREST	  	 	136	  
		 	48.	  	TERMINATION FOR CONVENIENCE	  	 	136	  
		 	49.	  	THIRD PARTY ANTITRUST VIOLATIONS	  	 	136	  
		 	50.	  	TYPE OF CONTRACT	  	 	136	  
		 	51.	  	WARRANTY OF SERVICES	  	 	136	  
		
	 SECTION F: ATTACHMENTS
	  	 	137	  
			
		 	ATTACHMENT F1. ENROLLEE GRIEVANCE SYSTEM STANDARDS	  	 	137	  
		 	ATTACHMENT F2. PROVIDER CLAIM DISPUTE STANDARDS	  	 	143	  
		 	ATTACHMENT F3. CONTRACTOR CHART OF DELIVERABLES	  	 	145	  
		
	 SECTION G: RESERVED
	  	 	172	  
		
	 SECTION H: RESERVED
	  	 	173	  
		
	 SECTION I: RESERVED
	  	 	174	  
		
	 ENDNOTES
	  	 	175	  


  
 Acute Care Contract 

10/01/2015 Renewal 
  

4 









			
	SECTION B:	 	
	CAPITATION RATES AND CONTRACTOR SPECIFIC REQS	 	Contract No. YH14-0001

  

 
  

SECTION B: CAPITATION RATES AND CONTRACTOR SPECIFIC REQUIREMENTS 

The Contractor shall provide services as described in this contract. In consideration for these services, the Contractor will be paid Contractor-specific rates
per member per month for the period October 1, 2015 through September 30, 2016 unless otherwise modified by contract amendment. 
  

			
	Capitation Rates:	 	See Contractor–specific Section B

  

			
	 Contractor Specific Requirements:
	 	See Contractor–specific Section B


  
 Acute Care Contract 

10/01/2015 Renewal 
 5 









			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  

SECTION C: DEFINITIONS 
 PART 1.
DEFINITIONS PERTAINING TO ALL AHCCCS CONTRACTS 
 The definitions specified in Part 1 below refer to terms found in all AHCCCS contracts. The definitions
specified in Part 2 below refer to terms that exist in one or more contracts but do not appear in all contracts. 
  

			
	638 TRIBAL FACILITY	  	A facility that is owned and/or operated by a Federally recognized American Indian/Alaskan Native Tribe and that is authorized to provide services pursuant to Public Law 93-638, as amended. Also referred to as: tribally owned and/or
operated 638 facility, tribally owned and/or operated facility, 638 tribal facility, and tribally-operated 638 health program.
		
	ABUSE (OF MEMBER)	  	Intentional infliction of physical, emotional or mental harm, caused by negligent acts or omissions, unreasonable confinement, sexual abuse or sexual assault as defined by A.R.S. §46-451 and A.R.S. §13-3623.
		
	ABUSE (BY PROVIDER)	  	Provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the AHCCCS program, or in reimbursement for services that are not medically necessary or that fail to
meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the AHCCCS program as defined by 42 CFR 455.2.
		
	ACUTE CARE CONTRACTOR	  	A contracted managed care organization (also known as a health plan) that provides acute care physical health services to AHCCCS members in the acute care program who are Title XIX or Title XXI eligible. The Acute Care Contractor is
also responsible for providing behavioral health services for its enrolled members who are treated by a Primary Care Provider (PCP) for anxiety, depression, and Attention Deficit Hyperactivity Disorder (ADHD). Effective October 1, 2015, Acute Care
Contractors are also responsible for providing behavioral health services for dual eligible adult members with General Mental Health and/or Substance Abuse (GMH/SA) needs. For other acute care populations, behavioral health services are carved out
and are provided through Tribal or Regional Behavioral Health Authorities.
		
	ACUTE CARE SERVICES	  	Medically necessary services that are covered for AHCCCS members and which are provided through contractual agreements with managed Care Contractors or on a Fee-For-Service (FFS) basis through AHCCCS.
		
	ADJUDICATED CLAIM	  	A claim that has been received and processed by the Contractor which resulted in a payment or denial of payment.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

6 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	ADMINISTRATIVE SERVICES SUBCONTRACTS	  	 An agreement that delegates any of the requirements of the contract with AHCCCS, including, but not limited to the following:

 
 a.     Claims
processing, including pharmacy claims,
  

b.     Credentialing, including those for only primary source verification (i.e. Credential
Verification Organization).
  

c.     Management Service Agreements;

 
 d.     Service Level
Agreements with any Division or Subsidiary of a corporate parent owner;
  

e.     DDD acute care and behavioral health subcontractors;

 
 f.     ADHS/DBHS
subcontracted Tribal/Regional Behavioral Health Authorities and the Integrated Regional Behavioral Health Authority.
  

Providers are not Administrative Services Subcontractors.

		
	AGENT	  	Any person who has been delegated the authority to obligate or act on behalf of a provider [42 CFR 455.101].
		
	AHCCCS CONTRACTOR OPERATIONS MANUAL (ACOM)	  	The ACOM provides information related to AHCCCS Contractor operations and is available on the AHCCCS website at www.azahcccs.gov.
		
	AHCCCS MEDICAL POLICY MANUAL (AMPM)	  	The AMPM provides information regarding covered health care services and is available on the AHCCCS website at www.azahcccs.gov.
		
	AHCCCS MEMBER	  	See “MEMBER.”
		
	AHCCCS RULES	  	See “ARIZONA ADMINISTRATIVE CODE.”
		
	AMERICAN INDIAN HEALTH PROGRAM (AIHP)	  	An acute care Fee-For-Service program administered by AHCCCS for eligible American Indians which reimburses for services provided by and through the Indian Health Service (IHS), tribal health programs operated under 638 or any other
AHCCCS registered provider. AIHP was formerly known as AHCCCS IHS.
		
	AMERICANS with DISABILITIES ACT (ADA)	  	The ADA prohibits discrimination on the basis of disability and ensures equal opportunity for persons with disabilities in employment, State and local government services, public accommodations, commercial facilities transportation,
and telecommunications. Refer to the Americans with Disabilities Act of 1990, as amended, in 42 U.S.C. 126 and 47 U.S.C. 5.
		
	APPEAL RESOLUTION	  	The written determination by the Contractor concerning an appeal.
		
	ARIZONA ADMINISTRATIVE CODE (A.A.C.)	  	State regulations established pursuant to relevant statutes. Referred to in Contract as “Rules.” AHCCCS Rules are State regulations which have been promulgated by the AHCCCS Administration and published by the Arizona
Secretary of State.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

7 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	 ARIZONA DEPARTMENT OF ECONOMIC SECURITY/

DIVISION OF DEVELOPMENTAL DISABILITIES (DES/DDD)
	  	The Division of a State agency, as defined in A.R.S. Title 36, Chapter 5.1, which is responsible for licensure/certification of facilities that specifically serve individuals with a developmental/intellectual disability, contracting
with providers that serve individuals with developmental disabilities, and providing services for eligible Arizona residents with a developmental/intellectual disability. AHCCCS contracts with ADES to serve eligible individuals with a
developmental/intellectual disability.
		
	ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS)	  	The state agency that has the powers and duties set forth in A.R.S. §36-104 and A.R.S. Title 36, Chapters 5 and 34.
		
	ARIZONA DEPARTMENT OF HEALTH SERVICES, DIVISION OF BEHAVIORAL HEALTH (ADHS/DBHS)	  	The state agency mandated to provide behavioral health services to Title XIX and Title XXI Acute care members who are eligible for behavioral health services. Services are provided through the ADHS Division of Behavioral Health and
its Contractors.
		
	ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS)	  	Arizona’s Medicaid Program, approved by the Centers for Medicare and Medicaid Services as a Section 1115 Waiver Demonstration Program and described in A.R.S. Title 36, Chapter 29.
		
	ARIZONA LONG TERM CARE SYSTEM (ALTCS)	  	An AHCCCS program which delivers long-term, acute, behavioral health and case management services as authorized by A.R.S. §36-2931 et seq., to eligible members who are either elderly and/or have physical disabilities, and to
members with developmental disabilities, through contractual agreements and other arrangements.
		
	ARIZONA REVISED STATUTES (A.R.S.)	  	Laws of the State of Arizona.
	AUTHORIZED REPRESENTATIVE	  	Authorized representative means a person who is authorized to apply for medical assistance or act on behalf of another person (A.A.C. R9-22-101).
		
	BALANCED BUDGET ACT (BBA)	  	See “MEDICAID MANAGED CARE REGULATIONS.”
		
	BEHAVIORAL HEALTH PROFESSIONAL	  	 As specified in A.A.C. R9-10-101, an individual licensed under A.R.S. Title 32, Chapter 33, whose scope of practice allows the individual
to:
  

a.     Independently engage in the practice of behavioral health as defined in A.R.S.
§32-3251; or
  

b.     Except for a licensed substance abuse technician, engage in the practice of behavioral
health as defined in A.R.S. §32-3251 under direct supervision as defined in A.A.C. R4-6-101.;
  

c.     A psychiatrist as defined in A.R.S. §36-501;

 
 d.     A psychologist as
defined in A.R.S. §32-2061;
  

e.     A physician;
  

f.     A registered nurse practitioner licensed as an adult psychiatric and mental health
nurse; or
  
 g.     A
behavior analyst as defined in A.R.S. §32-2091; or
  

h.     A registered nurse



  
 Acute Care Contract 

10/01/2015 Renewal 
  

8 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	BEHAVIORAL HEALTH RECIPIENT	  	A Title XIX or Title XXI acute care member who is receiving behavioral health services through ADHS and the subcontractors.
		
	BEHAVIORAL HEALTH SERVICES	  	Physician or practitioner services, nursing services, health-related services, or ancillary services provided to an individual to address the individual’s behavioral health issue.See also “COVERED SERVICES.”
		
	BOARD CERTIFIED	  	An individual who has successfully completed all prerequisites of the respective specialty board and successfully passed the required examination for certification and when applicable, requirements for maintenance of
certification.
		
	BORDER COMMUNITIES	  	Cities, towns or municipalities located in Arizona and within a designated geographic service area whose residents typically receive primary or emergency care in adjacent Geographic Service Areas (GSA) or neighboring states,
excluding neighboring countries, due to service availability or distance.
		
	CAPITATION	  	Payment to a Contractor by AHCCCS of a fixed monthly payment per person in advance, for which the Contractor provides a full range of covered services as authorized under A.R.S. §36-2904 and §36-2907.
		
	CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)	  	An organization within the United States Department of Health and Human Services, which administers the Medicare and Medicaid programs and the State Children’s Health Insurance Program.
		
	CHILDREN with SPECIAL HEALTH CARE NEEDS (CSHCN)	  	Children under age 19 who are blind, children with disabilities, and related populations (eligible for SSI under Title XVI). Children eligible under section 1902(e)(3) of the Social Security Act (Katie Beckett); in foster care or
other out-of-home placement; receiving foster care or adoption assistance; or receiving services through a family-centered, community-based coordinated care system that receives grant funds under section 501(a)(1)(D) of Title V (CRS).
		
	CLAIM DISPUTE	  	A dispute, filed by a provider or Contractor, whichever is applicable, involving a payment of a claim, denial of a claim, imposition of a sanction or reinsurance.
		
	CLEAN CLAIM	  	A claim that may be processed without obtaining additional information from the provider of service or from a third party but does not include claims under investigation for fraud or abuse or claims under review for medical
necessity, as defined by A.R.S. §36-2904.
		
	CODE OF FEDERAL REGULATIONS (CFR)	  	The general and permanent rules published in the Federal Register by the departments and agencies of the Federal Government.
		
	CONTRACT SERVICES	  	See “COVERED SERVICES.”
		
	CONTRACT YEAR (CY)	  	Corresponds to the contract year as specified in Section A of the contract.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

9 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	CONTRACT YEAR ENDING (CYE)	  	Corresponds to the contract ending year as specified in Section A of the contract.
		
	CONTRACTOR	  	An organization or entity that has a prepaid capitated contract with AHCCCS pursuant to A.R.S. §36-2904, §36-2940, or §36-2944to provide goods and services to members either directly or through subcontracts with
providers, in conformance with contractual requirements, AHCCCS Statute and Rules, and Federal law and regulations.
		
	CONVICTED	  	A judgment of conviction has been entered by a Federal, State or local court, regardless of whether an appeal from that judgment is pending.
		
	COPAYMENT	  	A monetary amount that the member pays directly to a provider at the time covered services are rendered, as defined in 9 A.A.C. 22, Article 7.
		
	CORRECTIVE ACTION PLAN (CAP)	  	A written work plan that identifies the root cause(s) of a deficiency, includes goals and objectives, actions/ tasks to be taken to facilitate an expedient return to compliance, methodologies to be used to accomplish CAP goals and
objectives, and staff responsible to carry out the CAP within established timelines. CAPs are generally used to improve performance of the Contractor and/or its providers, to enhance Quality Management/Process Improvement activities and the outcomes
of the activities, or to resolve a deficiency.
		
	COST AVOIDANCE	  	The process of identifying and utilizing all confirmed sources of first or third-party benefits before payment is made by the Contractor.
		
	COVERED SERVICES	  	The health and medical services to be delivered by the Contractor as described in Section D, Program Requirements.
		
	DAY	  	A day means a calendar day unless otherwise specified.
		
	DAY – BUSINESS/WORKING	  	A business day means a Monday, Tuesday, Wednesday, Thursday, or Friday unless a legal holiday falls on Monday, Tuesday, Wednesday, Thursday, or Friday.
		
	DELEGATED AGREEMENT	  	A type of subcontract agreement with a qualified organization or person to perform one or more functions required to be performed by the Contractor pursuant to this contract.
		
	DEPARTMENT OF CHILD SAFETY/COMPREHENSIVE MEDICAL AND DENTAL PLAN (DCS/CMDP)	  	On May 29, 2014 the Department of Child Safety was established pursuant to A.R.S. §8-451. Under the authority of DCS is CMDP, a Contractor that is responsible for the provisions of covered, medically necessary AHCCCS
services for children in foster care in Arizona. CMDP previously existed as a department within the Arizona Department of Economic Security (ADES).
		
	DISCLOSING ENTITY	  	An AHCCCS provider or a fiscal agent.
		
	DISENROLLMENT	  	The discontinuance of a member’s ability to receive covered services through a Contractor.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

10 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	DIVISION OF HEALTH CARE MANAGEMENT (DHCM)	  	The division responsible for Contractor oversight regarding AHCCCS Contractor operations, quality, maternal and child health, behavioral health, medical management, case management, rate setting, encounters, and
financial/operational oversight.
		
	DUAL ELIGIBLE	  	A member who is eligible for both Medicare and Medicaid.
		
	DURABLE MEDICAL EQUIPMENT (DME)	  	An item or appliance that is not an orthotic or prosthetic and that is: designed for a medical purpose, is generally not useful to a person in the absence of an illness or injury, can withstand repeated use, and is generally
reusable by others.
		
	EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT)	  	A comprehensive child health program of prevention, treatment, correction, and improvement of physical and mental health problems for AHCCCS members under the age of 21. The purpose of EPSDT is to ensure the availability and
accessibility of health care resources as well as to assist Medicaid recipients in effectively utilizing these resources. EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary
treatment, and follow-up care of physical and behavioral health problems for AHCCCS members less than 21 years of age. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary
mandatory and optional services listed in Federal Law 42 U.S.C. 1396d(a) to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS
State Plan. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services.
		
	EMERGENCY MEDICAL CONDITION	  	A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of
immediate medical attention to result in: a) placing the patient’s health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, b)serious impairment to bodily functions, or c) serious
dysfunction of any bodily organ or part [42 CFR 438.114(a)].
		
	EMERGENCY MEDICAL SERVICE	  	Covered inpatient and outpatient services provided after the sudden onset of an emergency medical condition as defined above. These services must be furnished by a qualified provider, and must be necessary to evaluate or stabilize
the emergency medical condition [42 CFR 438.114(a)].
		
	ENCOUNTER	  	A record of a health care-related service rendered by a provider or providers registered with AHCCCS to a member who is enrolled with a Contractor on the date of service.
		
	ENROLLEE	  	A Medicaid recipient who is currently enrolled with a Contractor [42 CFR 438.10(a)].


  
 Acute Care Contract 

10/01/2015 Renewal 
  

11 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	ENROLLMENT	  	The process by which an eligible person becomes a member of a Contractor’s plan.
		
	EXHIBITS	  	All items attached as part of the solicitation.
		
	FEDERAL FINANCIAL PARTICIPATION (FFP)	  	FFP refers to the contribution that the Federal government makes to the Title XIX and Title XXI program portions of AHCCCS, as defined in 42 CFR 400.203.
		
	FEE-FOR-SERVICE (FFS)	  	A method of payment to an AHCCCS registered provider on an amount-per-service basis for services reimbursed directly by AHCCCS for members not enrolled with a managed care Contractor.
		
	FEE-FOR-SERVICE MEMBER	  	A Title XIX or Title XXI eligible individual who is not enrolled with an AHCCCS Contractor.
		
	FISCAL AGENT	  	A Contractor that processes or pays vendor claims on behalf of the Medicaid agency [42 CFR 455.101].
		
	FRAUD	  	An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under
applicable State or Federal law, as defined in 42 CFR 455.2.
		
	GEOGRAPHIC SERVICE AREA (GSA)	  	An area designated by AHCCCS within which a Contractor of record provides, directly or through subcontract, covered health care service to a member enrolled with that Contractor of record, as defined in 9 A.A.C. 22, Article
1.
		
	GRIEVANCE SYSTEM	  	A system that includes a process for enrollee grievances, enrollee appeals, provider claim disputes, and access to the state fair hearing system.
		
	HEALTH CARE PROFESSIONAL	  	A physician, podiatrist, optometrist, chiropractor, psychologist, dentist, physician assistant, physical or occupational therapist, therapist assistant, speech language pathologist, audiologist, registered or practical nurse
(including nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist and certified nurse midwife), licensed social worker, registered respiratory therapist, licensed marriage and family therapist and licensed professional
counselor.
		
	HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)	  	The Health Insurance Portability and Accountability Act; also known as the Kennedy-Kassebaum Act, signed August 21, 1996 as amended and as reflected in the implementing regulations at 45 CFR Parts 160, 162, and 164.
		
	HEALTH PLAN	  	See “CONTRACTOR.”
		
	INCURRED BUT NOT REPORTED LIABILITY (IBNR)	  	Incurred but not reported liability for services rendered for which claims have not been received.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

12 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	INDIAN HEALTH SERVICES (IHS)	  	A Federal agency pursuant to 25 U.S.C. 1661.
		
	INFORMATION SYSTEMS	  	The component of the Offeror’s organization which supports the Information Systems, whether the systems themselves are internal to the organization (full spectrum of systems staffing), or externally contracted (internal
oversight and support).
		
	INTERGOVERNMENTAL AGREEMENT (IGA)	  	When authorized by legislative or other governing bodies, two or more public agencies or public procurement units by direct contract or agreement may contract for services or jointly exercise any powers common to the contracting
parties and may enter into agreements with one another for joint or cooperative action or may form a separate legal entity, including a nonprofit corporation to contract for or perform some or all of the services specified in the contract or
agreement or exercise those powers jointly held by the contracting parties. A.R.S. Title 11, Chapter 7, Article 3 (A.R.S. §11-952.A).
		
	LIABLE PARTY	  	An individual, entity, or program that is or may be liable to pay all or part of the medical cost of injury, disease or disability of an AHCCCS applicant or member as defined in A.A.C. R9-22-1001.
		
	LIEN	  	A legal claim, filed with the County Recorder’s office in which a member resides and in the county an injury was sustained for the purpose of ensuring that AHCCCS receives reimbursement for medical services paid. The lien is
attached to any settlement the member may receive as a result of an injury.
		
	MAJOR UPGRADE	  	Any systems upgrade or changes that may result in a disruption to the following: loading of contracts, providers or members, issuing prior authorizations or the adjudication of claims.
		
	MANAGED CARE	  	Systems that integrate the financing and delivery of health care services to covered individuals by means of arrangements with selected providers to furnish comprehensive services to members; establish explicit criteria for the
selection of health care providers; have financial incentives for members to use providers and procedures associated with the plan; and have formal programs for quality, medical management and the coordination of care.
		
	MANAGEMENT SERVICES AGREEMENT	  	A type of subcontract with an entity in which the owner of the Contractor delegates some or all of the comprehensive management and administrative services necessary for the operation of the Contractor.
		
	MATERIAL CHANGE TO BUSINESS OPERATIONS	  	Any change in overall operations that affects, or can reasonably be foreseen to affect, the Contractor’s ability to meet the performance standards as required in contract including, but not limited to, any change that would
impact or is likely to impact more than 5% of total membership and/or provider network in a specific GSA.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

13 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	MATERIAL CHANGE TO THE PROVIDER NETWORK	  	Any change that affects, or can reasonably be foreseen to affect, the Contractors’ ability to meet the performance and/or provider network standards as required in contract including, but not limited to, any change that would
cause or is likely to cause more than 5% of the members in a GSA to change the location where services are received or rendered.
		
	MANAGING EMPLOYEE	  	A general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over or who directly or indirectly conducts the day-to-day operation of an institution, organization
or agency [42 CFR 455.101].
		
	MATERIAL OMISSION	  	A fact, data or other information excluded from a report, contract, etc., the absence of which could lead to erroneous conclusions following reasonable review of such report, contract, etc.
		
	MEDICAID	  	A Federal/State program authorized by Title XIX of the Social Security Act, as amended.
		
	MEDICAID MANAGED CARE REGULATIONS	  	The Federal law mandating, in part, that States ensure the accessibility and delivery of quality health care by their managed care Contractors. These regulations were promulgated pursuant to the Balanced Budget Act (BBA) of
1997.
		
	MEDICARE	  	A Federal program authorized by Title XVIII of the Social Security Act, as amended.
		
	MEDICAL MANAGEMENT (MM)	  	An integrated process or system that is designed to assure appropriate utilization of health care resources, in the amount and duration necessary to achieve desired health outcomes, across the continuum of care (from prevention to
end of life care).
		
	MEDICAL SERVICES	  	Medical care and treatment provided by a Primary Care Provider (PCP), attending physician or dentist or by a nurse or other health related professional and technical personnel at the direction/order of a licensed physician or
dentist.
		
	MEDICALLY NECESSARY	  	As defined in 9 A.A.C. 22 Article 101. Medically necessary means a covered service provided by a physician or other licensed practitioner of the health arts within the scope of practice under State law to prevent disease, disability
or other adverse conditions or their progression, or prolong life.
		
	MEDICALLY NECESSARY SERVICES	  	Those covered services provided by qualified service providers within the scope of their practice to prevent disease, disability and other adverse health conditions or their progression or to prolong life.
		
	MEMBER	  	An eligible person who is enrolled in AHCCCS, as defined in A.R.S. §36-2931, §36-2901, §36-2901.01 and A.R.S. §36-2981.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

14 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	MEMBER INFORMATION MATERIALS	  	Any materials given to the Contractor’s membership. This includes, but is not limited to: member handbooks, member newsletters, surveys, on hold messages and health related brochures/reminders and videos, form letter templates,
and website content. It also includes the use of other mass communication technology such as e-mail and voice recorded information messages delivered to a member’s phone.
		
	NATIONAL PROVIDER IDENTIFIER (NPI)	  	A unique identification number for covered health care providers, assigned by the CMS contracted national enumerator.
		
	NON-CONTRACTING PROVIDER	  	A person or entity that provides services as prescribed in A.R.S. §36-2901 who does not have a subcontract with an AHCCCS Contractor.
		
	NOTICE OF APPEAL RESOLUTION	  	The written determination by the Contractor concerning an appeal.
		
	OFFEROR	  	An organization or other entity that submits a proposal to AHCCCS in response to a Request For Proposal as defined in 9 A.A.C. 22, Article 1.
		
	PARENT	  	A biological, adoptive, or custodial mother or father of a child, or an individual who has been appointed as a legal guardian or custodian of a child by a court of competent jurisdiction.
		
	PERFORMANCE IMPROVEMENT PROJECT (PIP)	  	A planned process of data gathering, evaluation and analysis to determine interventions or activities that are projected to have a positive outcome. A PIP includes measuring the impact of the interventions or activities toward
improving the quality of care and service delivery. Formerly referred to as Quality Improvement Projects (QIP).
		
	PERFORMANCE STANDARDS	  	A set of standardized measures designed to assist AHCCCS in evaluating, comparing and improving the performance of its Contractors.
		
	POST STABILIZATION CARE SERVICES	  	Medically necessary services, related to an emergency medical condition provided after the member’s condition is sufficiently stabilized in order to maintain, improve or resolve the member’s condition so that the member
could alternatively be safely discharged or transferred to another location [42 CFR 438-114(a)].
		
	POTENTIAL ENROLLEE	  	A Medicaid-eligible recipient who is not yet enrolled with a Contractor [42 CFR 438.10(a)].
		
	PREPAID MEDICAL MANAGEMENT INFORMATION SYSTEM (PMMIS)	  	An integrated information infrastructure that supports AHCCCS operations, administrative activities and reporting requirements.
		
	PREMIUM TAX	  	The premium tax is equal to the tax imposed pursuant to A.R.S. §36-2905 for all payments made to Contractors for the contract year.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

15 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	PRIMARY CARE PROVIDER (PCP)	  	An individual who meets the requirements of A.R.S. §36-2901, and who is responsible for the management of the member’s health care. A PCP may be a physician defined as a person licensed as an allopathic or osteopathic
physician according to A.R.S. Title 32, Chapter 13 or Chapter 17, or a practitioner defined as a physician assistant licensed under A.R.S. Title 32, Chapter 25, or a certified nurse practitioner licensed under A.R.S. Title 32, Chapter 15. The PCP
must be an individual, not a group or association of persons, such as a clinic.
		
	PRIOR PERIOD	  	See “PRIOR PERIOD COVERAGE.”
		
	 PRIOR PERIOD
 COVERAGE
(PPC)
	  	The period of time prior to the member’s enrollment, during which a member is eligible for covered services. The timeframe is from the effective date of eligibility (usually the first day of the month of application) until the
date the member is enrolled with the Contractor. Refer to 9 A.A.C. 22 Article 1. If a member made eligible via the Hospital Presumptive Eligibility (HPE) program is subsequently determined eligible for AHCCCS via the full application process, prior
period coverage for the member will be covered by AHCCCS Fee-For-Service and the member will be enrolled with the Contractor only on a prospective basis.
		
	PRIOR QUARTER COVERAGE	  	 The period of time prior to an individual’s month of application for AHCCCS coverage, during which a member may be eligible for covered
services. Prior Quarter Coverage is limited to the three month time period prior to the month of application. An applicant may be eligible during any of the three months prior to application if the applicant:

 
 1.     Received one or
more covered services described in 9 A.A.C. 22, Article 2 and Article 12, and 9 A.A.C. 28, Article 2 during the month; and
  

2.     Would have qualified for Medicaid at the time services were received if the person had
applied regardless of whether the person is alive when the application is made. Refer to A.A.C. R9-22-303
  

AHCCCS Contractors are not responsible for payment for covered services received during the prior quarter.

		
	PROGRAM CONTRACTOR	  	See “CONTRACTOR”
		
	PROVIDER	  	Any person or entity that contracts with AHCCCS or a Contractor for the provision of covered services to members according to the provisions A.R.S. §36-2901 or any subcontractor of a provider delivering services pursuant to
A.R.S. §36-2901.
		
	PROVIDER GROUP	  	Two or more health care professionals who practice their profession at a common location (whether or not they share facilities, supporting staff, or equipment).


  
 Acute Care Contract 

10/01/2015 Renewal 
  

16 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	 PRUDENT LAYPERSON
 (for purposes of
determining whether an emergency medical condition exists)
	  	A person without medical training who relies on the experience, knowledge and judgment of a reasonable person to make a decision regarding whether or not the absence of immediate medical attention will result in: 1) placing the
health of the individual in serious jeopardy, 2) serious impairment to bodily functions, or 3) serious dysfunction of a bodily part or organ.
		
	QUALIFIED MEDICARE BENEFICIARY DUAL ELIGIBLE (QMB DUAL)	  	A person determined eligible under Title 9 Chapter 29 Article 2 of A.A.C. for Qualified Medicare Beneficiary (QMB) and eligible for acute care services provided for in 9 A.A.C. 22 or ALTCS services provided for in 9 A.A.C. 28. A QMB
dual person receiving both Medicare and Medicaid services and cost sharing assistance.
		
	REFERRAL	  	A verbal, written, telephonic, electronic or in-person request for health services.
		
	REINSURANCE	  	A risk-sharing program provided by AHCCCS to Contractors for the reimbursement of certain contract service costs incurred for a member beyond a predetermined monetary threshold.
		
	RELATED PARTY	  	A party that has, or may have, the ability to control or significantly influence a Contractor, or a party that is, or may be, controlled or significantly influenced by a Contractor. “Related parties” include, but are not
limited to, agents, managing employees, persons with an ownership or controlling interest in the Offeror and their immediate families, subcontractors, wholly-owned subsidiaries or suppliers, parent companies, sister companies, holding companies, and
other entities controlled or managed by any such entities or persons.
		
	REQUEST FOR PROPOSAL (RFP)	  	A RFP includes all documents, whether attached or incorporated by references that are used by the Administration for soliciting a proposal under 9 A.A.C. 22 Article 6.
		
	ROOM AND BOARD (or ROOM)	  	The amount paid for food and/or shelter. Medicaid funds can be expended for room and board when a person lives in an institutional setting (e.g. NF, ICF). Medicaid funds cannot be expended for room and board when a member resides in
an alternative residential setting (e.g. Assisted Living Home, Behavioral Health Residential Facilities) or an apartment like setting that may provide meals.
		
	SCOPE OF SERVICES	  	See “COVERED SERVICES.”
		
	SERVICE LEVEL AGREEMENT	  	A type of subcontract with a corporate owner or any of its Divisions or Subsidiaries that requires specific levels of service for administrative functions or services for the Contractor specifically related to fulfilling the
Contractor’s obligations to AHCCCS under the terms of this contract.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

17 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	SERVICE PLAN	  	A document that is developed consistent with applicable Evidence Based Practice Guidelines, which combines the various elements of treatment plans with needed family support services and care coordination activities to provide a map
of the steps to be taken for each member in achieving treatment and quality of life goals.
		
	SPECIAL HEALTH CARE NEEDS	  	Serious or chronic physical, developmental and/or behavioral health conditions. Members with special health care needs require medically necessary services of a type or amount beyond that generally required by members.
		
	SPECIALTY PHYSICIAN	  	A physician who is specially trained in a certain branch of medicine related to specific services or procedures, certain age categories of patients, certain body systems, or certain types of diseases.
		
	STATE	  	The State of Arizona.
		
	STATEWIDE	  	Of sufficient scope and breadth to address the health care service needs of members throughout the State of Arizona.
		
	STATE FISCAL YEAR	  	The budget year-State fiscal year: July 1 through June 30.
		
	STATE PLAN	  	The written agreements between the State and CMS, which describes how the AHCCCS program meets CMS requirements for participation in the Medicaid program and the State Children’s Health Insurance Program.
		
	SUBCONTRACT	  	An agreement entered into by the Contractor with any of the following: a provider of health care services who agrees to furnish covered services to member; or with any other organization or person who agrees to perform any
administrative function or service for the Contractor specifically related to fulfilling the Contractor’s obligations to AHCCCS under the terms of this contract, as defined in 9 A.A.C. 22 Article 1.
		
	SUBCONTRACTOR	  	 1.     A provider of health care who agrees to furnish covered services to
members.
  
 2.     A
person, agency or organization with which the Contractor has contracted or delegated some of its management/administrative functions or responsibilities.
  

3.     A person, agency or organization with which a fiscal agent has entered into a
contract, agreement, purchase order or lease (or leases of real property) to obtain space, supplies equipment or services provided under the AHCCCS agreement.

		
	SUPPLEMENTAL SECURITY INCOME (SSI) AND SSI RELATED GROUPS	  	Eligible individuals receiving income through Federal cash assistance programs under Title XVI of the Social Security Act who are aged, blind or have a disability and have household income levels at or below 100% of the
FPL.
		
	THIRD PARTY LIABILITY (TPL)	  	See “LIABLE PARTY.”


  
 Acute Care Contract 

10/01/2015 Renewal 
  

18 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	TITLE XIX	  	Known as Medicaid, Title XIX of the Social Security Act provides for Federal grants to the states for medical assistance programs. Title XIX enables states to furnish medical assistance to those who have insufficient income and
resources to meet the costs of necessary medical services, rehabilitation and other services, to help those families and individuals become or remain independent and able to care for themselves. Title XIX members include but are not limited to those
eligible under Section 1931 of the Social Security Act, Supplemental Security Income (SSI), SSI-related groups, Medicare cost sharing groups, Breast and Cervical Cancer Treatment Program and Freedom to Work Program. Which include those populations
42 U.S.C. 1396 a(a)(10)(A).
		
	TITLE XIX MEMBER	  	Title XIX members include those eligible under 1931 provisions of the Social Security Act (previously AFDC), Sixth Omnibus Budget Reconciliation Act (SOBRA), Supplemental Security Income (SSI) or SSI-related groups, Medicare Cost
Sharing groups, Adult Group at or below 106% Federal Poverty Level (Adults </= 106%), Adult Group above 106% Federal Poverty Level (Adults > 106%), Breast and Cervical Cancer Treatment program, Title IV-E Foster Care and Adoption Subsidy,
Young Adult Transitional Insurance, and Freedom to Work.
		
	TREATMENT	  	A procedure or method to cure, improve, or palliate an individual’s medical condition or behavioral health issue. Refer to A.A.C. R9-10-101.
		
	TRIBAL/REGIONAL BEHAVIORAL HEALTH AUTHORITY (T/RBHA)	  	An organization under contract with the State of Arizona that administers covered behavioral health services for Title XIX and XXI members. Tribal governments, through an agreement with the State, may operate a Tribal Regional
Behavioral Health Authority for the provision of behavioral health services to American Indian members. Refer to A.R.S. §36-3401, §36-3407, and A.A.C. R9-22-1201.
		
	YEAR	  	See “CONTRACT YEAR.”

 [END OF PART 1 DEFINITIONS] 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

19 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  

 SECTION C: DEFINITIONS 

PART 2. DEFINITIONS PERTAINING TO ONE OR MORE AHCCCS CONTRACTS 
  

			
		
	 1931 (ALSO REFERRED
 TO AS TANF
RELATED)
	  	 Eligible individuals and families under Section 1931 of the Social Security Act, with household income levels at or below 100% of the Federal
Poverty Level (FPL).
  
 See also “TEMPORARY ASSISTANCE TO NEEDY FAMILIES
(TANF).”

		
	 ACUTE CARE
 ONLY (ACO)
	  	ACO refers to the enrollment status of a member who is otherwise financially and medically eligible for ALTCS but who either 1) refuses HCBS offered by the case manager; 2) has made an uncompensated transfer that makes him or her
ineligible; 3) resides in a setting in which Long Term Care Services cannot be provided; or 4) has equity value in a home that exceeds $525,000. These ALTCS enrolled members are eligible to receive acute medical services but not eligible to
receive LTC institutional, alternative residential or HCBS.
		
	ADMINISTRATIVE OFFICE OF THE COURTS (AOC)	  	The Arizona Constitution authorizes an administrative director and staff to assist the Chief Justice with administrative duties. Under the direction of the Chief Justice, the administrative director and the staff of the
Administrative Office of the Courts (AOC) provide the necessary support for the supervision and administration of all State courts.
		
	ADULT GROUP ABOVE 106% FEDERAL POVERTY LEVEL (ADULTS > 106%)	  	Adults aged 19-64, without Medicare, with income above 106% through 133% of the Federal Poverty Level (FPL).
		
	 ADULT GROUP AT OR BELOW 106% FEDERAL POVERTY LEVEL

(ADULTS </= 106%)
	  	Adults aged 19-64, without Medicare, with income at or below 106% of the Federal Poverty Level (FPL).
		
	AGENT	  	Any person who has been delegated the authority to obligate or act on behalf of another person or entity.
		
	AHCCCS BENEFITS	  	See “Section D, Scope of Services”.
		
	AID FOR FAMILIES WITH DEPENDENT CHILDREN (AFDC)	  	See “TEMPORARY ASSISTANCE TO NEEDY FAMILIES (TANF).”
		
	AMBULATORY CARE	  	Preventive, diagnostic and treatment services provided on an outpatient basis by physicians, nurse practitioners physician assistants and other health care providers.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

20 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	ANNIVERSARY DATE	  	The anniversary date is 12 months from the date the member enrolled with the Contractor and annually thereafter. In some cases, the anniversary date will change based on the last date the member changed Contractors or the last date
the member was given an opportunity to change.
		
	ANNUAL ENROLLMENT CHOICE (AEC)	  	The opportunity for a person to change Contractors every 12 months.
		
	ARIZONA DEPARTMENT OF CHILD SAFETY (DCS)	  	 The department established pursuant to A.R.S. §8-451 to protect children and to perform the following:

 
 1.     Investigate
reports of abuse and neglect.
  

2.     Assess, promote and support the safety of a child in a safe and stable family or other
appropriate placement in response to allegations of abuse or neglect.
  

3.     Work cooperatively with law enforcement regarding reports that include criminal
conduct allegations.
  

4.     Without compromising child safety, coordinate services to achieve and maintain
permanency on behalf of the child, strengthen the family and provide prevention, intervention and treatment services pursuant to this chapter.

		
	ARIZONA DEPARTMENT OF JUVENILE CORRECTION (ADJC)	  	Arizona Department of Juvenile Correction.
		
	BED HOLD	  	A 24 hour per day unit of service that is authorized by an ALTCS member’s case manager or the behavioral health case manager or a subcontractor for an acute care member, which may be billed despite the member’s absence
from the facility for the purposes of short term hospitalization leave and therapeutic leave. Refer to the Arizona Medicaid State Plan, 42 C.F.R. §§447.40 and 483.12, and 9 A.A.C. 28 for more information on the bed hold service and AMPM
Chapter 100.
		
	BEHAVIORAL HEALTH PARAPROFESSIONAL	  	 As specified in A.A.C. R9-10-101, an individual who is not a behavioral health professional who provides behavioral health services at or for
a health care institution according to the health care institution’s policies and procedures that:
  

a.     If the behavioral health services were provided in a setting other than a licensed
health care institution, the individual would be required to be licensed as a behavioral professional under A.R.S. Title 32, Chapter 33; and
  

b.     Are provided under supervision by a behavioral health professional.

		
	BEHAVIORAL HEALTH TECHNICIAN	  	 As specified in A.A.C. R9-10-101, an individual who is not a behavioral health professional who provides behavioral health services at or for
a health care institution according to the health care institution’s policies and procedures that:
  

a.     If the behavioral health services were provided in a setting other than a licensed
health care institution, the individual would be required to be licensed as a behavioral professional under A.R.S. Title 32, Chapter 33; and
  

b.     Are provided with clinical oversight by a behavioral health
professional.



  
 Acute Care Contract 

10/01/2015 Renewal 
  

21 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	BREAST AND CERVICAL CANCER TREATMENT PROGRAM (BCCTP)	  	Eligible individuals under the Title XIX expansion program for women with income up to 250% of the FPL, who are diagnosed with and need treatment for breast and/or cervical cancer or cervical lesions and are not eligible for other
Title XIX programs providing full Title XIX services. Qualifying individuals cannot have other creditable health insurance coverage, including Medicare.
		
	CASE MANAGER	  	An individual as described in Arizona Administrative Code, Title 9, Chapter 21 and Chapter 28, and Title 6, Chapter 6.
		
	CASH MANAGEMENT IMPROVEMENT ACT (CMIA)	  	Cash Management Improvement Act of 1990 [31 CFR Part 205]. Provides guidelines for the drawdown and transfer of Federal funds.
		
	CHILDREN’S REHABILITATIVE SERVICES (CRS)	  	A program that provides medical treatment, rehabilitation, and related support services to Title XIX and Title XXI members who have completed the CRS application and have met the eligibility criteria to receive CRS-related services
as specified in 9 A.A.C. 22.
		
	CLIENT ASSESSMENT AND TRACKING SYSTEM (CATS)	  	A component of AHCCCS’ data management information system that supports ALTCS and that is designed to provide key information to, and receive key information from ALTCS Contractors.
		
	COMPREHENSIVE MEDICAL AND DENTAL PROGRAM (CMDP)	  	A Contractor that is responsible for the provision of covered, medically necessary AHCCCS services for foster children in Arizona. Refer to A.R.S. §8-512.
		
	COMPETITIVE BID PROCESS	  	A state procurement system used to select Contractors to provide covered services on a geographic basis.
		
	COUNTY OF FISCAL RESPONSIBILITY	  	The county of fiscal responsibility is the Arizona county that is responsible for paying the state’s funding match for the member’s ALTCS Service Package. The county of physical presence (the county in which the member
physically resides) and the county of fiscal responsibility may be the same county or different counties.
		
	CRS-ELIGIBLE	  	An individual AHCCCS member who has completed the CRS application process, as delineated in the CRS Policy and Procedure Manual, and has met all applicable criteria to be eligible to receive CRS-related services as specified
in 9 A.A.C. 22.
		
	CRS RECIPIENT	  	An individual who has completed the CRS application process, and has met all applicable criteria to be eligible to receive CRS related covered Services.
		
	DEPARTMENT OF ECONOMIC SECURITY (DES)	  	Department of Economic Security.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

22 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	DEVELOPMENTAL DISABILITY (DD)	  	 As defined in A.R.S. §36-551, a strongly demonstrated potential that a child under six years of age has a developmental disability or
will become a child with a developmental disability, as determined by a test performed pursuant to section 36-694 or by other appropriate tests, or a severe, chronic disability that:

 
 a.     Is attributable
to cognitive disability, cerebral palsy, epilepsy or autism.
  

b.     Is manifested before age eighteen.

 
 c.     Is likely to
continue indefinitely.
  

d.     Results in substantial functional limitations in three or more of the following areas
of major life activity:
  
 (i) Self-care.

 
 (ii) Receptive and expressive language.

 
 (iii) Learning.

 
 (iv) Mobility.

 
 (v) Self-direction.

 
 (vi) Capacity for independent living.

 
 (vii) Economic self-sufficiency.

 
 e.     Reflects the need
for a combination and sequence of individually planned or coordinated special, interdisciplinary or generic care, treatment or other services that are of lifelong or extended duration.

		
	FAMILY-CENTERED	  	Care that recognizes and respects the pivotal role of the family in the lives of members. It supports families in their natural care-giving roles, promotes normal patterns of living, and ensures family collaboration and choice in
the provision of services to the member.
		
	FAMILY OR FAMILY MEMBER	  	A biological, adoptive, or custodial mother or father of a child, or an individual who has been appointed as a legal guardian or custodian of a child by a court of competent jurisdiction, or other member representative responsible
for making health care decisions on behalf of the member. Family members may also include siblings, grandparents, aunts and uncles.
		
	FEDERAL EMERGENCY SERVICES (FES)	  	A program delineated in A.A.C. R9-22-217, to treat an emergency condition for a member who is determined eligible under A.R.S. §36-2903.03(D).
		
	FEDERALLY QUALIFIED HEALTH CENTER (FQHC)	  	A public or private non-profit health care organization that has been identified by the HRSA and certified by CMS as meeting criteria under Sections 1861(aa)(4) and 1905(l)(2)(B) of the Social Security Act.
		
	FEDERALLY QUALIFIED HEALTH CENTER LOOK-ALIKE	  	A public or private non-profit health care organization that has been identified by the HRSA and certified by CMS as meeting the definition of “health center” under Section 330 of the Public Health Service Act, but does
not receive grant funding under Section 330.
		
	FIELD CLINIC	  	A “clinic” consisting of single specialty health care providers who travel to health care delivery settings closer to members and their families than the Multi-Specialty Interdisciplinary Clinics (MSICs) to provide a
specific set of services including evaluation, monitoring, and treatment for CRS-related conditions on a periodic basis.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

23 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	FREEDOM OF CHOICE (FC)	  	The opportunity given to each member who does not specify a Contractor preference at the time of enrollment to choose between the Contractors available within the Geographic Service Area (GSA) in which the member is
enrolled.
		
	HOME	  	A residential dwelling that is owned, rented, leased, or occupied at no cost to the member, including a house, a mobile home, an apartment or other similar shelter. A home is not a facility, a setting or an institution, or a portion
and any of these, licensed or certified by a regulatory agency of the state as a defined in A.A.C. R9-28-101.
		
	HOME AND COMMUNITY BASED SERVICES (HCBS)	  	Home and community-based services, as defined in A.R.S. §36-2931 and §36-2939.
		
	INTEGRATED MEDICAL RECORD	  	A single document in which all of the medical information listed in Chapter 900 of the AMPM is recorded to facilitate the coordination and quality of care delivered by multiple providers serving a single patient in multiple
locations and at varying times.
		
	INTEGRATED REGIONAL BEHAVIORAL HEALTH AUTHORITY (INTEGRATED RBHA)	  	An organization that provides behavioral health services to AHCCCS members who are Title XIX or Title XXI eligible, other than adult members dually enrolled in Medicaid and Medicare with General Mental Health and Substance Abuse
needs and American Indians who choose a TRBHA. The Integrated RBHA also provides physical health services for AHCCCS members determined to have a Serious Mental Illness, with the exception of American Indians who choose AIHP.
		
	INTERDISCIPLINARY CARE	  	A meeting of the interdisciplinary team members or coordination of care among interdisciplinary treatment team members to address the totality of the treatment and service plans for the member based on the most current information
available.
		
	INTERMEDIATE CARE FACILITY FOR PERSONS WITH INTELLECTUAL DISABILITIES (ICF)	  	A placement setting for persons with intellectual disabilities.
		
	JUVENILE PROBATION OFFICE (JPO)	  	Juvenile Probation Office.
		
	KIDSCARE	  	Federal and State Children’s Health Insurance Program (Title XXI – CHIP) administered by AHCCCS. The KidsCare I program offers comprehensive medical, preventive, treatment services, and behavioral health care services
statewide to eligible children under the age of 19, in households with income at or below 200% Federal Poverty Level (FPL). The KidsCare II program has the same benefits and premium requirements as KidsCare I, however household income limits cannot
be greater than 175% FPL. The KidsCare II program is available May 1, 2012 through January 31, 2014.
		
	MEDICAL PRACTITIONER	  	A physician, physician assistant or registered nurse practitioner.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

24 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	MEDICARE MANAGED CARE PLAN	  	A managed care entity that has a Medicare contract with CMS to provide services to Medicare beneficiaries, including Medicare Advantage Plan (MAP), Medicare Advantage Prescription Drug Plan (MAPDP), MAPDP Special Needs Plan, or
Medicare Prescription Drug Plan.
		
	MULTI-SPECIALTY INTERDISCIPLINARY CLINIC (MSIC)	  	An established facility where specialists from multiple specialties meet with members and their families for the purpose of providing interdisciplinary services to treat members.
		
	PERSON WITH A DEVELOPMENTAL/INTELLECTUAL DISABILITY	  	An individual who meets the Arizona definition as outlined in A.R.S. §36-551 and is determined eligible for services through the DES Division of Developmental Disabilities (DDD). Services for AHCCCS-enrolled acute and long term
care members with developmental/intellectual disabilities are managed through the DES Division of Developmental Disabilities.
		
	PRE-ADMISSION SCREENING (PAS)	  	A process of determining an individual’s risk of institutionalization at a NF or ICF level of care as specified in 9 A.A.C. 28 Article 1.
		
	RATE CODE	  	Eligibility classification for capitation payment purposes.
		
	RISK GROUP	  	Grouping of rate codes that are paid at the same capitation rate.
		
	ROSTER BILLING	  	Any claim that does not meet the standardized claim requirements of 9 A.A.C. 22, Article 7 is considered roster billing.
		
	RURAL HEALTH CLINIC (RHC)	  	A clinic located in an area designated by the Bureau of Census as rural, and by the Secretary of the DHHS as medically underserved or having an insufficient number of physicians, which meets the requirements under 42 CFR
491.
		
	SERIOUSLY MENTALLY ILL (SMI)	  	A person 18 years of age or older who has been determined to have a serious mental illness as defined in A.R.S. §36-550.
		
	SIXTH OMNIBUS BUDGET AND RECONCILIATION ACT (SOBRA)	  	Eligible pregnant women under Section 9401 of the Sixth Omnibus Budget and Reconciliation Act of 1986, amended by the Medicare Catastrophic Coverage Act of 1988, 42 U.S.C. 1396(a)(10)(A)(ii)(IX), November 5, 1990, with individually
budgeted incomes at or below 150% of the FPL, and children in families with individually budgeted incomes ranging from below 100% to 140% of the FPL, depending on the age of the child.
		
	STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP)	  	State Children’s Health Insurance Program under Title XXI of the Social Security Act (Also known as CHIP). The Arizona version of CHIP is referred to as “KidsCare.” See also “KIDSCARE.”
		
	STATE ONLY TRANSPLANT MEMBERS	  	Individuals who are eligible under one of the Title XIX eligibility categories and found eligible for a transplant, but subsequently lose Title XIX eligibility due to excess income become eligible for one of two extended eligibility
options as specified in A.R.S. §36-2907.10 and A.R.S. §36-2907.11.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

25 










			
	SECTION C: DEFINITIONS	 	Contract No. YH14-0001

  

 
  


			
		
	SUBSTANCE ABUSE	  	 As specified in A.A.C. R9-10-101, an individual’s misuse of alcohol or other drug or chemical that:

 
 a.     Alters the
individual’s behavior or mental functioning;
  

b.     Has the potential to cause the individual to be psychologically or physiologically
dependent on alcohol or other drug or chemical; and
  

c.     Impairs, reduces, or destroys the individual’s social or economic
functioning.

		
	TELEMEDICINE	  	The practice of health care delivery, diagnosis, consultation and treatment and the transfer of medical data through interactive audio, video or data communications that occur in the physical presence of the patient, including audio
or video communications sent to a health care provider for diagnostic or treatment consultation. Refer to A.R.S. §36-3601.
		
	TEMPORARY ASSISTANCE TO NEEDY FAMILIES (TANF)	  	A Federal cash assistance program under Title IV of the Social Security Act established by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193). It replaced Aid To Families With Dependent
Children (AFDC).
		
	TITLE XXI	  	Title XXI of the Social Security Act provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low income children in an effective and efficient manner that is coordinated
with other sources of child health benefits coverage.
		
	TITLE XXI MEMBER	  	Member eligible for acute care services under Title XXI of the Social Security Act, referred to in Federal legislation as the “Children’s Health Insurance Program” (CHIP ). The Arizona version of CHIP is referred to
as “KidsCare.”
		
	TREATMENT PLAN	  	A written plan of services and therapeutic interventions based on a complete assessment of a member’s developmental and health status, strengths and needs that are designed and periodically updated by the multi-specialty,
interdisciplinary team.
		
	VIRTUAL CLINICS	  	Integrated services provided in community settings through the use of innovative strategies for care coordination such as Telemedicine, integrated medical records and virtual interdisciplinary treatment team meetings.

 [END OF PART 2 DEFINITIONS] 

[END OF SECTION C] 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

26 









			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

SECTION D: ACUTE CARE PROGRAM REQUIREMENTS 
 1. PURPOSE,
APPLICABILITY, AND INTRODUCTION 
 PURPOSE AND APPLICABILITY 

The purpose of the contract between AHCCCS and the Contractor is to implement and operate the Arizona Acute Care Program pursuant to A.R.S. §36-2901 et
seq. 
 In the event that a provision of Federal or State law, regulation, or policy is repealed or modified during the term of this contract, effective on
the date the repeal or modification by its own terms takes effect: 
  

	1.	The provisions of this contract shall be deemed to have been amended to incorporate the repeal or modification; and 

  

	2.	The Contractor shall comply with the requirements of the contract as amended, unless AHCCCS and the Contractor otherwise stipulate in writing. 


INTRODUCTION 
 AHCCCS Mission and Vision

 AHCCCS’ mission and vision are to reach across Arizona to provide comprehensive quality healthcare to those in need while shaping tomorrow’s
managed health care from today’s experience, quality and innovation. AHCCCS is dedicated to continuously improving the efficiency and effectiveness of the Acute Care Program while supporting member choice in the delivery of the highest quality
care to its customers. 
 AHCCCS expects the Contractor to implement program innovation and best practices on an ongoing basis. Furthermore, it is important
for the Contractor to continuously develop mechanisms to reduce administrative cost and improve program efficiency. Over the term of the contract, AHCCCS will work collaboratively with the Contractor to evaluate ways to reduce program complexity,
improve care coordination and chronic disease management, reduce administrative burdens, leverage joint purchasing power, and reduce unnecessary administrative and medical costs. 

AHCCCS has remained a leader in Medicaid Managed Care through the diligent pursuit of excellence and cost effective managed care by its collaboration with
Contractors. 
 The Contractor must continue to add value to the program. A Contractor adds value when it: 

 

	 	•	 	Recognizes that Medicaid members are entitled to care and assistance navigating the service delivery system and demonstrates special effort throughout its operations to assure members receive necessary services.


  

	 	•	 	Recognizes that Medicaid members with special health care needs or chronic health conditions require care coordination, and provides that coordination. 


 

	 	•	 	Recognizes that health care providers are an essential partner in the delivery of health care services, and operates the Health Plan in a manner that is efficient and effective for health care providers as well as the
Contractor. 

  

	 	•	 	Recognizes that performance improvement is both clinical and operational in nature and self-monitors and self-corrects as necessary to improve contract compliance or operational excellence. 


 

	 	•	 	Recognizes that the program is publicly funded, is subject to public scrutiny, and operates in a manner consistent with the public trust. 


The Acute Care Program 
 In 1982 Arizona introduced its
innovative Medicaid program by establishing the Arizona Health Care Cost Containment System (AHCCCS), a demonstration program based on principles of managed care. In doing so, AHCCCS became the first statewide Medicaid managed care system in the
nation. As of October 1, 2012, AHCCCS, through its Managed Care Organizations (MCOs) serves 1,062,361 members under the Acute Care Program. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

27 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 AHCCCS contracts for acute care services in seven geographic service areas that include the 15 Arizona
counties. Contractors are responsible for coordinating, managing and providing acute care services to members and coordinating carved out behavioral health services delivered by the Regional Behavioral Health Authorities through the Arizona
Department of Health Services. 
 Additional information may be obtained by visiting the AHCCCS website: www.azahcccs.gov. 

2. ELIGIBILITY CATEGORIES 
 AHCCCS is Arizona’s Title
XIX Medicaid program operating under an 1115 Waiver and Title XXI program operating under Title XXI State Plan authority. Arizona has the authority to require mandatory enrollment in managed care. All Acute Care Program members eligible for AHCCCS
benefits, with exceptions as identified below, are enrolled with Acute Care Contractors that are paid on a capitated basis. AHCCCS pays for health care expenses on a Fee-For-Service (FFS) basis for Title XIX- and Title XXI- eligible members who
receive services through the American Indian Health Program; for Title XIX eligible members who are entitled to emergency services under the Federal Emergency Services (FES) program; and for Medicare cost sharing beneficiaries under the QMB-Only
program. 
 The Contractor is not responsible for determining eligibility. 

The following describes the eligibility groups enrolled in the managed care program and covered under this contract [42 CFR 434.6(a)(2)]: 

Title XIX 
 1931 (Also referred to
as TANF-related): Eligible individuals and families under the 1931 provision of the Social Security Act, with income at or below 100% of the FPL. 

SSI Cash: Eligible individuals receiving Supplemental Security Income through Federal cash assistance programs under Title XVI of
the Social Security Act who are aged, blind or who have a disability and have income at or below 100% of the Federal Benefit Rate (FBR). 

SSI Medical Assistance Only (SSI MAO) and Related Groups: Eligible individuals who are aged, blind or who have a disability and
have household income levels at or below 100% of the FPL. 
 Freedom to Work (Ticket to Work): Eligible individuals under the
Title XIX program that extends eligibility to individuals 16 through 64 years old who meet SSI disability criteria, and whose earned income after allowable deductions is at or below 250% of the FPL, and who are not eligible for any other Medicaid
program. These members must pay a premium to AHCCCS, depending on income. 
 SOBRA: Under the Sixth Omnibus Budget
Reconciliation Act of 1986, eligible pregnant women, with income at or below 150% of the FPL, and children with individually budgeted incomes ranging from below 100% to 140% of the FPL, depending on the age of the child. 

Breast and Cervical Cancer Treatment Program (BCCTP): Eligible individuals under the Title XIX expansion program for women with
incomes at or below 250% of the FPL, who are diagnosed with and need treatment for breast and/or cervical cancer or cervical lesions and are not eligible for other Title XIX programs. Eligible members cannot have other creditable health insurance
coverage, including Medicare. 
 Title IV-E Foster Care and Adoption Subsidy: Children who are in State foster care or are
receiving Federally funded adoption subsidy payments. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

28 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Young Adult Transitional Insurance (YATI): Transitional medical care for
individuals age 18 through age 25 who were enrolled in the foster care program under jurisdiction of the Department of Child Safety in Arizona on their 18th birthday. 

Adult Group at or below 106% FPL: Adults aged 19-64, without Medicare, with income at or below 106% of the Federal Poverty Level
(Adults </= 106%). 
 Adult Group above 106% FPL: Adults aged 19-64, without Medicare, with income above 106% through 133%
of the Federal Poverty Level (Adults > 106%). 
 Title XXI 

KidsCare: Federal and State Children’s Health Insurance Program (Title XXI – CHIP) administered by AHCCCS. The KidsCare
I program offers comprehensive medical, preventive, treatment services, and behavioral health care services statewide to eligible children under the age of 19, in households with income at or below 200% Federal Poverty Level (FPL). The KidsCare II
program (terminated January 31, 2014) has the same benefits and premium requirements as KidsCare I, however household income limits cannot be greater than 175% FPL. 

State-Only 
 State-Only
Transplants: Title XIX individuals, for whom medical necessity for a transplant has been established and who subsequently lose Title XIX eligibility may become eligible for and select one of two extended eligibility options as specified in
A.R.S. §36-2907.10 and A.R.S. §36-2907.11. The extended eligibility is authorized only for those individuals who have met all of the following conditions: 

 

	 	1.	The individual has been determined ineligible for Title XIX due to excess income; 

  

	 	2.	The individual had been placed on a donor waiting list before eligibility expired; and 

  

	 	3.	The individual has entered into a contractual arrangement with the transplant facility to pay the amount of income which is in excess of the eligibility income standards (referred to as transplant share of cost).


 The following options for extended eligibility are available to these members: 

Option 1: Extended eligibility is for one 12-month period immediately following the loss of AHCCCS eligibility. The member is eligible
for all AHCCCS covered services as long as they continue to be medically eligible for a transplant. If determined medically ineligible for a transplant at any time during the period, eligibility will terminate at the end of the calendar month in
which the determination is made. 
 Option 2: The member loses AHCCCS eligibility but maintains transplant candidacy status as long as
medical eligibility for a transplant is maintained. At the time that the transplant is scheduled to be performed the transplant candidate will reapply and will be re-enrolled with his/her previous Contractor to receive all covered transplant
services. Option 2-eligible individuals are not eligible for any non-transplant related health care services from AHCCCS. 
 3. ENROLLMENT AND
DISENROLLMENT 
 AHCCCS Acute Care members are enrolled with the Contractor in accordance with the rules set forth in 9 A.A.C. 22 Article 17, and 9
A.A.C. 31 Articles 3 and 17. AHCCCS has the exclusive authority to enroll and disenroll members. AHCCCS does not use passive enrollment procedures [42 CFR 438.6(d)(2)]. AHCCCS operates as a mandatory managed care program and choice of enrollment or
auto-assignment is used pursuant to the terms of the Arizona Medicaid Section 1115 Demonstration Waiver Special Terms and Conditions.i The 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

29 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 
Contractor shall not disenroll any member for any reason unless directed to do so by AHCCCS [42 CFR 438.56(d)(5)(iii)]. The Contractor may request AHCCCS to change the member’s enrollment in
accordance with ACOM Policy 401. The Contractor may not request disenrollment because of an adverse change in the enrollee’s health status, nor because of the enrollee’s utilization of medical services, diminished mental capacity, or
uncooperative or disruptive behavior resulting from his or her special needs. An AHCCCS member may request disenrollment from the Contractor for cause at any time. Refer to ACOM Policy 401. 

AHCCCS will disenroll the member from the Contractor when: 
  

	 	•	 	The member becomes ineligible for the AHCCCS program; 

  

	 	•	 	In limited situations when the member moves out of the Contractor’s service areas; 

  

	 	•	 	The member changes Contractors during the member’s open enrollment and annual enrollment choice period; 

  

	 	•	 	The Contractor does not, because of moral or religious objections, cover the service the member seeks unless the Contractor offered a solution that was accepted by AHCCCS in accordance with the requirements in Section
D, Paragraph 10, Scope of Services; 

  

	 	•	 	The member is approved for a Contractor change through ACOM Policy 401 [42 CFR 438.56]; or 

  

	 	•	 	The member is eligible to transition to another AHCCCS program. 

 Members may submit plan change requests to
the Contractor or AHCCCS. A denial of any plan change request must include the Contractor’s reason for not approving the change and options for resolution. The notice must advise the member of the AHCCCS and Contractors grievance policies. The
notice must also advise the member of his/her right to request a hearing, including how to request a hearing and the timeframe for making the request. 

Member Choice of Contractor: AHCCCS members eligible for services covered under this contract have a choice of available Contractors, except
those populations described below. 
  

	a.	Previously enrolled members who have been disenrolled for less than 90 days will be automatically enrolled with the same Contractor, if still available. 


 

	b.	Members residing in a Geographic Service Area where only one Contractor is available will be automatically enrolled with that Contractor and will be given a choice of PCPs. 


AHCCCS members eligible under this contract who become eligible for another AHCCCS program will be enrolled as follows: 

 

	a.	Members eligible for Children’s Rehabilitative Services will be enrolled with the CRS Contractor, unless they refuse to participate in the CRS application process, refuse to receive CRS covered services through the
CRS Program, or opt out of CRS Program. This includes members who are eligible for CRS who are determined to have a Serious Mental Illness (SMI). 

  

	b.	Adult members determined to have a Serious Mental Illness will be enrolled in an Integrated RBHA. 

  

	c.	Children in State custody will be enrolled in CMDP. 

 Members who do not choose a Contractor prior to AHCCCS
being notified of their eligibility are automatically assigned to a Contractor based on re-enrollment rules, family continuity, or the auto-assignment algorithm. If a member is auto-assigned, AHCCCS sends a Choice Notice to the member and allows the
member 30 days to choose a different Contractor. See Section D, Paragraph 6, Auto-Assignment Algorithm, for further explanation. 
 The effective date of
enrollment for a new Title XIX member with the Contractor is the day AHCCCS takes the enrollment action. The Contractor is responsible for payment of medically necessary covered services retroactive to the member’s beginning date of
eligibility, as reflected in PMMIS. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

30 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 The effective date of enrollment for a Title XXI member will be the first day of the month following
notification to the Contractor. In the event that eligibility is determined on or after the 25th day of the month, eligibility will begin on the first day of the second month following the
determination. 
 Prior Quarter Coverage: Pursuant to Federal Regulation 42 CFR 435.915, AHCCCS is required to implement Prior
Quarter Coverage eligibility which expands the time period during which AHCCCS pays for covered services for eligible individuals to include services provided during any of the three months prior to the month the individual applied for AHCCCS, if
the individual met AHCCCS eligibility requirements during that month. AHCCCS Contractors are not responsible for payment for covered services received during the prior quarter. Upon verification or notification of Prior Quarter Coverage eligibility,
providers will be required to bill AHCCCS for services provided during a prior quarter eligibility period.  
 Prior Period Coverage:
AHCCCS provides Prior Period Coverage for the period of time prior to the Title XIX member’s enrollment during which the member is eligible for covered services. Prior Period Coverage refers to the time frame from the effective date of
eligibility (usually the first day of the month of application) until the date the member is enrolled with the Contractor. The Contractor receives notification from AHCCCS of the member’s enrollment. The Contractor is responsible for payment of
all claims for medically necessary covered services, excluding most behavioral health services, provided to members during prior period coverage. This may include services provided prior to the contract year and in a Geographic Service Area where
the Contractor was not contracted at the time of service delivery. AHCCCS Fee-For-Service will be responsible for the payment of claims for prior period coverage for members who are found eligible for AHCCCS initially through Hospital Presumptive
Eligibility and later are enrolled with the Contractor. Therefore, for those members, the Contractor is not responsible for Prior Period Coverage. 

Newborns: Newborns born to AHCCCS eligible mothers enrolled at the time of the child’s birth will be enrolled with the mother’s
Contractor (except as noted in the following paragraph), when newborn notification is received by AHCCCS. The Contractor is responsible for notifying AHCCCS of a child’s birth to an enrolled member. Capitation for the newborn will be
retroactive to the date of birth if notification is received no later than one day from the date of birth. In all other circumstances, capitation for the newborn will begin on the date notification is received by AHCCCS. The effective date of AHCCCS
eligibility for the newborn will be the newborn’s date of birth, and the Contractor is responsible for all covered services to the newborn, whether or not AHCCCS has received notification of the child’s birth. AHCCCS is available to
receive notification 24 hours a day, seven days a week via the AHCCCS website. Each eligible mother of a newborn is sent a Choice notice advising her of her right to choose a different Contractor for her child; the date of the change will be the
date of processing the request from the mother. If the mother does not request a change within 30 days, the child will remain with the mother’s Contractor. 

Babies born to mothers enrolled in the Federal Emergency Services (FES) program , an Integrated RBHA, CRS, or CMDP are auto-assigned to an Acute Care
Contractor. Mothers of these newborns are sent a Choice Notice advising them of their right to choose a different Contractor for their child, which allows them 30 days to make a choice. In the event the mother chooses a different Contractor, AHCCCS
will recoup all capitation paid to the originally assigned Contractor and the baby will be enrolled retroactive to the date of birth with the second Contractor. The second Contractor will receive prior period capitation from the date of birth to the
day before assignment and prospective capitation from the date of assignment forward. The second Contractor will be responsible for all covered services to the newborn from date of birth. 

Enrollment Guarantees: Upon initial capitated enrollment as a Title XIX-eligible member, the member is guaranteed a minimum of five full months
of continuous enrollment. Upon initial capitated enrollment as a Title XXI-eligible member, the member is guaranteed a minimum of 12 full months of continuous enrollment. The enrollment guarantee is a one-time benefit. If a member changes from one
Contractor to another within the enrollment guarantee period, the remainder of the guarantee period applies to the new Contractor. AHCCCS rules at 9 A.A.C 22 Article 17, and 9 A.A.C. 31 Article 3, describe other reasons for which the enrollment
guarantee may not apply. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

31 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 American Indians: If a choice is not made prior to AHCCCS being notified of their eligibility,
American Indian Title XIX members living on-reservation will be assigned to the AHCCCS American Indian Health Program (AIHP) as FFS members. American Indian Title XIX members living off-reservation who do not make a Contractor choice will be
assigned to an available Contractor using the AHCCCS protocol for family continuity and the auto-assignment algorithm. The designation of a zip code as a ‘reservation zip code’, not the physical location of the residence, is the factor
that determines whether a member is considered on or off-reservation for these purposes. Further, if the member resides in a zip code that contains land on both sides of a reservation boundary and the zip code is assigned as off-reservation, the
physical location of the residence does not change the off-reservation designation for the member. American Indian members can change enrollment between American Indian Health Plan (AIHP) or a Contractor at any time. However, a member can change
from one Contractor to another only once a year. American Indian members, title XIX and XXI, on- or off-reservation, eligible to receive services, may choose to receive services at any time from an American Indian Health Facility (I/T/U)—Indian
Health Service (IHS) Facility, a Tribally-Operated 638 Health Program, Urban Indian Health Program) [ARRA Section 5006(d), and SMD letter 10-001].ii The Contractor shall not impose enrollment
fees, premiums, or similar charges on American Indians served by an American Indian Health Facility (I/T/U)—Indian Health Service (IHS) Facility, a Tribally-Operated 638 Health Program, Urban Indian Health Program) (ARRA Section 5006(d),
SMD letter 10-001).iii 
 4. ANNUAL AND OPEN ENROLLMENT CHOICE 

AHCCCS conducts an Annual Enrollment Choice (AEC) for members in Geographic Service Areas (GSAs) with multiple Contractors on their annual anniversary date [42
CFR 438.56(c)(2)(ii)]. During AEC, members may change Contractors subject to the availability of other Contractors within their GSA. AHCCCS provides enrollment and other information required by Medicaid Managed Care Regulations 60 days prior to the
member’s AEC date. The member may choose a new Contractor by contacting AHCCCS to complete the enrollment process. If the member does not participate in the AEC, no change of Contractor will be made (except for approved changes under ACOM
Policy 401) during the new anniversary year. This holds true if a Contractor’s contract is renewed and the member continues to live in a Contractor’s service area. The Contractor shall comply with ACOM Policy 402, and the AMPM. 

AHCCCS may hold an open enrollment in any GSA or combination of GSAs as deemed necessary. 

5. RESERVED 
 6. AUTO-ASSIGNMENT
ALGORITHM 
 Members who do not exercise their right to choose and do not have family continuity are assigned to a Contractor through an auto-assignment
algorithm. The algorithm is a mathematical formula used to distribute members to the various Contractors in a manner that is predictable and consistent with AHCCCS goals. 

Assignment by the algorithm applies to the following members who do not exercise their right to choose a Contractor within the prescribed time limits: 

 

	1.	New members and members re-enrolling outside the 90-day re-enrollment window. 

  

	2.	Members enrolled with a Contractor that is not available after the member moves to a new Geographic Service Area (GSA). 

  

	3.	Infants born to a mother who is enrolled with the Maricopa County Integrated RBHA and diagnosed as Seriously Mentally Ill (SMI) and who has no family continuity with an AHCCCS Acute Care Contractor in Maricopa County.


  

	4.	Members who were enrolled with the Maricopa County Integrated RBHA and diagnosed as SMI but who have been determined to no longer qualify as SMI and who do not have family continuity with an AHCCCS Acute Care Contractor
in Maricopa County. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

32 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	5.	Members who are disenrolled from the CRS Contractor and who do not have family continuity with an AHCCCS Acute Care Contractor. 


Once auto-assigned, AHCCCS sends a Choice notice to the member, allowing the member 30 days to choose a different Contractor from the auto-assigned
Contractor. 
 AHCCCS may change the algorithm at any time during the term of the contract in response to Contractor-specific issues (e.g. imposition of an
enrollment cap) or in the best interest of the AHCCCS Program and/or the State. 
 Maximum Enrollment: A Contractor in Maricopa or Pima County
will no longer be eligible for auto assignment of members once the Contractor’s membership reaches 45% of the County’s total enrollment. Member choices will not be impacted by the auto assignment algorithm freeze. 

For further details on the AHCCCS Auto-Assignment Algorithm, refer to ACOM Policy 314. 

7. AHCCCS MEMBER IDENTIFICATION CARDS 
 The Contractor is
responsible for the production, distribution and costs of AHCCCS member identification cards and the AHCCCS Notice of Privacy Practices in accordance with ACOM Policy 433. See also Attachment F3, Contractor Chart of Deliverables. 

8. MAINSTREAMING OF AHCCCS MEMBERS 
 To ensure
mainstreaming of AHCCCS members, the Contractor shall take affirmative action so that members are provided covered services without regard to payer source, race, color, creed, gender, religion, age, national origin (to include those with limited
English proficiency), ancestry, marital status, sexual preference, genetic information, or physical or mental illnesses. The Contractor must take into account a member’s literacy and culture when addressing members and their concerns, and must
take reasonable steps to ensure subcontractors to do the same. The Contractor must also make interpreters, including assistance for the visual- or hearing- impaired, available to members at no cost to ensure appropriate delivery of covered services.

 Examples of prohibited practices include, but are not limited to, the following, in accordance with 42 CFR 438.6(f): 

 

	a.	Denying or not providing a member any covered service or access to an available facility; 

  

	b.	Providing to a member any medically necessary covered service which is different, or is provided in a different manner or at a different time from that provided to other members, other public or private patients or the
public at large, except where medically necessary; 

  

	c.	Subjecting a member to segregation or separate treatment in any manner related to the receipt of any covered service; restricting a member in any way in his or her enjoyment of any advantage or privilege enjoyed by
others receiving any covered service; and 

  

	d.	Assigning times or places for the provision of services on the basis of the race, color, creed, religion, age, gender, national origin, ancestry, marital status, sexual preference, income status, AHCCCS membership, or
physical or mental illnesses of the participants to be served. 

 If the Contractor knowingly executes a subcontract with a provider with the
intent of allowing or permitting the subcontractor to implement barriers to care (i.e. the terms of the subcontract act to discourage the full utilization of services by some members) the Contractor will be in default of its Contract. 

If the Contractor identifies a problem involving discrimination by one of its providers, it shall promptly intervene and require a corrective action plan from
the provider. Failure to take prompt corrective measures may place the Contractor in default of its Contract. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

33 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 9. TRANSITION ACTIVITIES 

Member Transition: The Contractor shall comply with the AMPM and the ACOM standards for member transitions between Contractors or Geographical
Service Areas (GSAs), Children’s Rehabilitative Services (CRS), the Comprehensive Medical and Dental Program (CMDP), or to the Arizona Long Term Care System (ALTCS) Contractor, and upon termination or expiration of a contract. The Contractor
shall develop and implement policies and procedures which include but are not limited to: 
  

	a.	Members with significant medical conditions such as, a high-risk pregnancy or pregnancy within the last trimester, the need for organ or tissue transplantation, chronic illness resulting in hospitalization or nursing
facility placement, etc.; 

  

	b.	Members who are receiving ongoing services such as dialysis, home health, chemotherapy and/or radiation therapy, or who are hospitalized at the time of transition; 


 

	c.	Members who have conditions requiring ongoing monitoring or screening such as elevated blood lead levels and members who were in the Neonatal Intensive Care Unit (NICU) after birth; 


 

	d.	Members who frequently contact AHCCCS, State and local officials, the Governor’s Office and/or the media; 

  

	e.	Members who have received prior authorization for services such as scheduled surgeries, post-surgical follow-up visits, out-of-area specialty services, or nursing home admission; 


 

	f.	Continuing prescriptions, Durable Medical Equipment (DME) and medically necessary transportation ordered for the transitioning member by the relinquishing Contractor; and 


 

	g.	Medical records of the transitioning member (the cost, if any, of reproducing and forwarding medical records shall be the responsibility of the relinquishing AHCCCS Contractor). 


The Contractor shall designate a person with appropriate training and experience to act as the Transition Coordinator. The individual appointed to this
position must be a health care professional or an individual who possesses the appropriate education and experience and is supported by a health care professional to effectively coordinate and oversee all transition issues, responsibilities, and
activities. This staff person shall interact closely with the transition staff of the receiving Contractor to ensure a safe, timely, and orderly transition. See ACOM Policy 402 for more information regarding the role and responsibilities of the
Transition Coordinator. 
 A new Contractor who receives members from another Contractor as a result of a contract award shall ensure a smooth transition
for members by continuing previously approved prior authorizations for 30 days after the member transition unless mutually agreed to by the member or member’s representative. 

When relinquishing members, the Contractor is responsible for timely notification to the receiving Contractor regarding pertinent information related to any
special needs of transitioning members. When receiving a transitioning member with special needs, the Contractor is responsible for coordinating care with the relinquishing Contractor in order that services are not interrupted, and for providing the
new member with Contractor and service information, emergency numbers and instructions about how to obtain services. See ACOM Policy 402 and AMPM Chapter 500. 

For individuals determined to have a Serious Mental Illness (SMI) who are transitioning from a health plan to an Integrated RBHA, there shall be a 14 day
transition period in order to ensure effective coordination of care. The Contractor shall comply with the AMPM and the ACOM standards for member transitions between Contractors as outlined above. The Contractor is responsible for the provision of
services outlined in this contract during the 14 day transition period. 
 Contract Termination: In the event that the contract or any portion
thereof is terminated for any reason, or expires, the Contractor shall assist AHCCCS in the transition of its members to other Contractors. In addition, AHCCCS reserves the right to extend the term of the contract on a month-to-month basis to assist
in any transition of members. AHCCCS may discontinue enrollment of new members with the Contractor three months prior to the contract termination date. The Contractor shall make provisions for continuing all


  
 Acute Care Contract 

10/01/2015 Renewal 
  

34 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 
management and administrative services until the transition of all members is completed and all other requirements of this contract are satisfied. The Contractor shall submit a detailed plan to
AHCCCS for approval regarding the transition of members in the event of contract expiration or termination. The name and title of the Contractor’s transition coordinator shall be included in the transition plan. The Contractor shall be
responsible for providing all reports set forth in this contract and necessary for the transition process, and shall be responsible for the following [42 CFR 438.610(c)(3); 42 CFR 434.6(a)(6)]: 

 

	a.	Notifying subcontractors and members; 

  

	b.	Paying all outstanding obligations for medical care rendered to members until AHCCCS is satisfied that the Contractor has paid all such obligations. The Contractor shall provide a monthly claims aging report including
IBNR amounts (due the 15th day of the month, for the prior month); 

  

	c.	Providing Quarterly and Audited Financial Statements up to the date of contract termination. The financial statement requirement will not be absolved without an official release from AHCCCS; 


 

	d.	Continuing encounter reporting until all services rendered prior to contract termination have reached adjudicated status and data validation of the information has been completed, as communicated by a letter of release
from AHCCCS; 

  

	e.	Cooperating with reinsurance audit activities on prior contract years until release has been granted by AHCCCS; 

  

	f.	Cooperating with AHCCCS to complete and finalize any open reconciliations, until release has been granted by AHCCCS. AHCCCS will work to complete any pending reconciliations as timely as can be completed, allowing for
appropriate lag time for claims run-out and/or changes to be entered into the system; 

  

	g.	Submitting quarterly Quality Management and Medical Management reports as required by Section D, Paragraphs 23, Quality Management, and 24, Medical Management, as appropriate to provide AHCCCS with information on
services rendered up to the date of contract termination. This will include Quality Of Care (QOC) concern reporting based on the date of service; 

  

	h.	Participating in and closing out Performance Measures and Performance Improvement Projects as requested by AHCCCS; 

  

	i.	Maintaining a Performance Bond in accordance with Section D, Paragraph 46, Performance Bond or Bond Substitute. A formal request to release the performance bond, as well as a balance sheet, must be submitted when
appropriate; 

  

	j.	Indemnifying AHCCCS for any claim by any third party against the State or AHCCCS arising from the Contractor’s performance of this contract and for which the Contractor would otherwise be liable under this
contract; 

  

	k.	Returning to AHCCCS, any funds advanced to the Contractor for coverage of members for periods after the date of termination. Funds must be returned to AHCCCS within 30 days of termination of the contract;


  

	l.	Providing a monthly accounting of Member Grievances and Claim Disputes and their disposition; and 

  

	m.	Preserving and making available all records for a period of five years from the date of final payment under contract. Records covered under HIPAA must be preserved and made available for six years per 45 CFR
164.530(j)(2). 

 The above list is not exhaustive and additional information may be requested to ensure that all operational and reporting
requirements have been met. Any dispute by the Contractor, with respect to termination or suspension of this contract by AHCCCS, shall be exclusively governed by the provisions of Section E, Contract Terms and Conditions, Paragraph 19, Disputes.

 ADULT DUAL MEMBERS RECEIVING GENERAL MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES 

For the October 1, 2015 integration of general mental health and substance abuse services to an Acute Care Contractor for adult dual members, previously
approved prior authorizations shall be continued by the Acute Care Contractor for a period of 90 days unless mutually agreed to by the member or member’s representative. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

35 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 10. SCOPE OF SERVICES 

The Contractor shall provide covered services to AHCCCS members in accordance with all applicable Federal and State laws, regulations and policies, including
those listed by reference in attachments and this contract. The services are described in detail in AHCCCS rules A.A.C. R9-22 Article 2, the AHCCCS Medical Policy Manual (AMPM) and the AHCCCS Contractor Operations Manual (ACOM), all of which
are incorporated herein by reference, and may be found on the AHCCCS website [42 CFR 400(a)(1)]. To be covered, services must be medically necessary and cost effective. The covered services are briefly described below. Except for annual well woman
exams, behavioral health and children’s dental services, and consistent with the terms of the demonstration, covered services must be provided by or coordinated with a primary care provider. 

The Contractor must ensure the coordination of services it provides with services the member receives from other entities, including behavioral health
services the member receives through an ADHS/RBHA provider. The Contractor shall ensure that, in the process of coordinating care, each member’s privacy is protected in accordance with the privacy requirements including, but not limited to, 45
CFR Parts 160 and 164, Subparts A and E, and Arizona statute, to the extent that they are applicable [42 CFR 438.208 (b)(2) and (b)(4) and 438.224]. 
 The
Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) with respect to any amount expended for which funds may not be used
under the Assisted Suicide Funding Restriction Act of 1997. (1903(i) final sentence and 1903(i)(16) of the Social Security Act).iv 

Services must be rendered by providers that are appropriately licensed or certified, operating within their scope of practice, and registered as an AHCCCS
provider. The Contractor shall provide the same standard of care for all members, regardless of the member’s eligibility category. The Contractor shall ensure that the services are sufficient in amount, duration and scope to reasonably be
expected to achieve the purpose for which the services are furnished [42 CFR 434.6(a)(4)]. The Contractor shall not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or
condition of the member [42 CFR 438.210(a)(3)(ii)]. The Contractor may place appropriate limits on a service on the basis of criteria such as medical necessity; or for utilization control, provided the services furnished can reasonably be expected
to achieve their purpose [42 CFR 438.210(a)(3); 42 CFR 438.210(a)(4)]. 
 Moral or Religious Objections 

The Contractor must notify AHCCCS if, on the basis of moral or religious grounds, it elects to not provide or reimburse for a covered service. The Contractor
may propose a solution to allow members’ access to the services. AHCCCS does not intend to offer the services on a Fee-For-Service basis to the Contractor’s enrollees. If AHCCCS does not approve the Contractor’s proposed solution,
AHCCCS will disenroll members who are seeking these services from the Contractor and assign them to another Contractor [42 CFR 438.56]. That proposal must: 
  

	 	•	 	Be submitted to AHCCCS in writing prior to entering into a contract with AHCCCS or at least 60 days prior to the intended effective date of the change in the scope of services based on moral or religious grounds;


  

	 	•	 	Place no financial or administrative burden on AHCCCS; 

  

	 	•	 	Place no significant burden on members’ access to the services; 

  

	 	•	 	Be accepted by AHCCCS in writing; and 

  

	 	•	 	Acknowledge an adjustment to capitation, depending on the nature of the proposed solution. 

 If AHCCCS approves
the Contractor’s proposed solution for its members to access the services, the Contractor must notify members how to access these services when directed by AHCCCS. The notification and policy must be consistent with the provisions of 42 CFR
438.10, must be provided to newly assigned members within 12 days of enrollment, and must be provided to all current members at least 30 days prior to the effective date of the approved policy [42 CFR 438.102(a)(2) and (b)(1)]. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

36 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Authorization of Services 

The Contractor shall have in place and follow written policies and procedures for the processing of requests for initial and continuing authorizations of
services. The Contractor shall have mechanisms in place to ensure consistent application of review criteria for authorization decisions. Any decision to deny a service authorization request or to authorize a service in an amount, duration or scope
that is less than requested, shall be made by a health care professional who has appropriate clinical expertise in treating the member’s condition or disease [42 CFR 438.210(b)]. 

Notice of Action 
 The Contractor shall notify the
requesting provider and give the member written notice of any decision by the Contractor to deny, reduce, suspend or terminate a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested
[42 CFR 438.400(b)]. The notice shall meet the requirements of 42 CFR 438.404, AHCCCS rules and ACOM Policy 414. The notice to the provider must also be in writing as specified in Attachment F1, Enrollee Grievance System Standards of this contract
[42 CFR 438.210(c)]. The Contractor must comply with all decision timelines outlined in ACOM Policy 414. 
 The Contractor shall ensure that its providers,
acting within the lawful scope of their practice are not prohibited or otherwise restricted from advising or advocating, on behalf of a member who is his or her patient, for [42 CFR 438.102]: 

 

	a.	The member’s health status, medical care or treatment options, including any alternative treatment that may be self-administered [42 CFR 438.100(b)(2)]; 


 

	b.	Any information the member needs in order to decide among all relevant treatment options; 

  

	c.	The risks, benefits, and consequences of treatment or non-treatment; and, 

  

	d.	The member’s right to participate in decisions regarding his or her behavioral health care, including the right to refuse treatment, and to express preferences about future treatment decisions [42 CFR
438.100(b)(2)(iv)]. 

 Covered Services 

Refer to the AHCCCS Medical Policy Manual (AMPM) for a comprehensive list of Covered Services. 

Ambulatory Surgery: The Contractor shall provide surgical services for either emergency or scheduled surgeries when provided in an ambulatory or
outpatient setting, such as a freestanding surgical center or a hospital-based outpatient surgical setting. 
 American Indian Health Program
(AIHP): The AHCCCS, Division of Fee-For-Service Management (DFSM) will reimburse claims for acute care services that are medically necessary, and are provided to Title XIX members enrolled with the Contractor by an IHS or 638 tribal
facility, eligible for 100% Federal reimbursement, when the member is eligible to receive services through an IHS or 638 tribal facility. Encounters for Title XIX services billed by an IHS or tribal facilities will not be accepted by AHCCCS or
considered in capitation rate development. 
 The Contractor is responsible for reimbursement to IHS or tribal facilities for services provided to Title XXI
American Indian members enrolled with the Contractor. The Contractor may choose to subcontract with an IHS or 638 tribal facility as part of its provider network for the delivery of Title XXI covered services. Expenses incurred by the Contractor for
Title XXI services billed by an IHS or 638 tribal facility shall be encountered and considered in capitation rate development. 
 Anti-hemophilic
Agents and Related Services: The Contractor shall provide services for the treatment of hemophilia and von Willebrand’s disease. See Section D, Paragraph 57, Reinsurance. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

37 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Audiology: The Contractor shall provide medically necessary audiology services to evaluate
hearing loss for all members, on both an inpatient and outpatient basis. Hearing aids are covered only for members under the age of 21 receiving EPSDT services. 

Behavioral Health: The Contractor shall provide behavioral health services as described in Section D, Paragraph 12, Behavioral Health Services.

 Children’s Rehabilitative Services: The Children’s Rehabilitative Services (CRS) program is administered by AHCCCS
utilizing a CRS Contractor for children with special health care needs who meet CRS eligibility criteria. The CRS Contractor provides various combinations of acute, behavioral health and specialty CRS services for these children. The Contractor
shall refer children to AHCCCS Division of Member Services (DMS) who are potentially eligible for services related to CRS-covered conditions, as specified in A.A.C. R9-22 Article 13, and A.R.S. Title 36. See ACOM Policy 426 for the processes used to
accept and process referrals to the CRS Program. In addition, the Contractor shall notify the member when a referral to CRS has been made. The Contractor is responsible for care of members until those members are determined eligible for CRS by
AHCCCS, Division of Member Services. In addition, the Contractor is responsible for CRS covered services for CRS-eligible members unless and until the Contractor has received confirmation from AHCCCS that the member has transitioned to the CRS
Contractor. For more detailed information regarding eligibility criteria, referral practices, and Contractor-CRS coordination issues, refer to the AHCCCS Medical Policy Manual (AMPM) and the AHCCCS Contractor’s Operation Manual (ACOM) located
on the AHCCCS website. 
 Chiropractic Services: The Contractor shall provide chiropractic services to members under age 21 when prescribed by
the member’s PCP and approved by the Contractor in order to ameliorate the member’s medical condition. For Qualified Medicare Beneficiaries, regardless of age, Medicare approved chiropractic services shall be covered subject to limitations
specified in 42 CFR 410.21. 
 Dialysis: The Contractor shall provide medically necessary dialysis, supplies, diagnostic testing and
medication for all members when provided by Medicare-certified hospitals or Medicare-certified end stage renal disease (ESRD) providers. Services may be provided on an outpatient basis or on an inpatient basis if the hospital admission is not solely
to provide chronic dialysis services. 
 Early and Periodic Screening, Diagnostic and Treatment (EPSDT): The Contractor shall provide
comprehensive health care services through primary prevention, early intervention, diagnosis and medically necessary treatment to correct or ameliorate defects and physical or mental illnesses discovered by the screenings for members under age 21.
The Contractor shall ensure that these members receive required health screenings, including developmental and behavioral health screenings, in compliance with the AHCCCS EPSDT Periodicity Schedule, and the AHCCCS Dental Periodicity Schedule
(Exhibit 430-1 and 430-1A in the AMPM), including appropriate oral health screening intended to identify oral pathology, including tooth decay and/or oral lesions, and the application of fluoride varnish conducted by a physician, physician’s
assistant or nurse practitioner. 
 The Contractor shall ensure the initiation and coordination of a referral as indicated on the EPSDT forms received, to
the T/RBHA system for members in need of behavioral health services. The Contractor shall have processes in place to follow up with the T/RBHA to monitor whether members have received these EPSDT services. The Contractor will ensure the coordination
of referrals and follow-up collaboration, as necessary, for members identified by the T/RBHA as needing acute care services. 
 Early Detection Health
Risk Assessment, Screening, Treatment and Primary Prevention: The Contractor shall provide health care services through screening, diagnostic and medically necessary treatment for members 21 years of age and older. These services include,
but are not limited to, screening and treatment for hypertension; elevated cholesterol; colon cancer; sexually transmitted diseases; tuberculosis; HIV/AIDS; 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

38 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 
breast cancer, cervical cancer; and prostate cancer. Nutritional assessment and treatment are covered when medically necessary to meet the needs of members who may have a chronic debilitating
disease. Physical examinations, diagnostic work-ups and medically necessary immunizations are also covered as specified in A.A.C. R9-22-205. 

Emergency Services: The Contractor shall provide emergency services per the following: 

 

	a.	Emergency services facilities adequately staffed by qualified medical professionals to provide pre-hospital, emergency care on a 24-hour-a-day, seven-day-a-week basis, for an emergency medical condition as defined by
A.A.C. R9-22 Article 1. Emergency medical services are covered without prior authorization. The Contractor is encouraged to contract with emergency service facilities for the provision of emergency services. The Contractor shall be responsible for
educating members and providers regarding appropriate utilization of emergency room services including behavioral health emergencies. The Contractor shall monitor emergency service utilization (by both provider and member) and shall have guidelines
for implementing corrective action for inappropriate utilization. For utilization review, the test for appropriateness of the request for emergency services shall be whether a prudent layperson, similarly situated, would have requested such
services. For the purposes of this contract, a prudent layperson is a person who possesses an average knowledge of health and medicine. 

  

	b.	All medical services necessary to rule out an emergency condition; and 

  

	c.	Emergency transportation. 

 Per the Medicaid Managed Care regulations, 42 CFR 438.114, 422.113, 422.133 the
following conditions apply with respect to coverage and payment of emergency services: 
 The Contractor must cover and pay for emergency services
regardless of whether the provider that furnishes the service has a contract with the Contractor. 
 The Contractor may not deny payment for treatment
obtained under either of the following circumstances: 
  

	a.	A member had an emergency medical condition, including cases in which the absence of medical attention would not have resulted in the outcomes identified in the definition of emergency medical condition under 42 CFR
438.114. 

  

	b.	A representative of the Contractor (an employee or subcontracting provider) instructs the member to seek emergency medical services. 


Additionally, the Contractor may not: 
  

	a.	Limit what constitutes an emergency medical condition as defined in 42 CFR 438.114, on the basis of lists of diagnoses or symptoms. 

  


	b.	Refuse to cover emergency services based on the failure of the emergency room provider, hospital, or fiscal agent to notify the Contractor of the member’s screening and treatment within 10 calendar days of
presentation for emergency services. Claims submission by the hospital within 10 calendar days of the member’s presentation for the emergency services constitutes notice to the Contractor. This notification stipulation is only related to the
provision of emergency services. 

  

	c.	Require notification of Emergency Department treat and release visits as a condition of payment unless the plan has prior approval from AHCCCS. 


A member who has an emergency medical condition may not be held liable for payment of subsequent screening and treatment needed to diagnose the specific
condition or stabilize the patient. 
 The attending emergency physician, or the provider actually treating the member, is responsible for determining when
the member is sufficiently stabilized for transfer or discharge, and such determination is binding on the Contractor responsible for coverage and payment. The Contractor shall comply with Medicaid Managed Care guidelines regarding the coordination
of post-stabilization care. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

39 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 For additional information and requirements regarding emergency services, refer to AHCCCS rules A.A.C.
R9-22-201 et seq. and 42 CFR 438.114. 
 Family Planning: The Contractor shall provide family planning services in accordance with the
AMPM, and consistent with the terms of the demonstration, for all members who choose to delay or prevent pregnancy. These include medical, surgical, pharmacological and laboratory services, as well as contraceptive devices. Information and
counseling, which allow members to make informed decisions regarding family planning methods, are also included. If the Contractor does not provide family planning services due to moral and religious objections, it must contract for these services
through another health care delivery system or have an approved alternative in place, or AHCCCS will disenroll members who are seeking these services from the Contractor and assign them to another Contractor. 

Foot and Ankle Services: 

Children: The Contractor shall provide foot and ankle services for members under the age of 21 to include bunionectomies, casting for
the purpose of constructing or accommodating orthotics, medically necessary orthopedic shoes that are an integral part of a brace, and medically necessary routine foot care for patients with a severe systemic disease that prohibits care by a
non-professional person. 
 Adults: The Contractor shall provide foot and ankle care services to include wound care, treatment of
pressure ulcers, fracture care, reconstructive surgeries, and limited bunionectomy services. Medically necessary routine foot care services are only available for members with a severe systemic disease that prohibits care by a non-professional
person as described in the AMPM. Services are not covered for members 21 years of age and older, when provided by a podiatrist or podiatric surgeon. 

Home and Community Based Services: Assisted living facility, alternative residential setting, or Home and Community Based Services (HCBS) as
defined in A.A.C. R9-22 Article 2, and A.A.C. R9-28 Article 2 that meet the provider standards described in A.A.C. R9-28 Article 5, and subject to the limitations set forth in the AMPM. These services are covered in lieu of a nursing
facility. 
 Home Health: This service shall be provided under the direction of a physician to prevent hospitalization or institutionalization
and may include nursing, therapies, supplies and home health aide services. It shall be provided on a part-time or intermittent basis. 

Hospice: These services are covered for members who are certified by a physician as being terminally ill and having six months or less to live.
See the AMPM for details on covered hospice services. 
 Hospital: Inpatient services include semi-private accommodations for routine care,
intensive and coronary care, surgical care, obstetrics and newborn nurseries, and behavioral health emergency/crisis services. If the member’s medical condition requires isolation, private inpatient accommodations are covered. Nursing services,
dietary services and ancillary services such as laboratory, radiology, pharmaceuticals, medical supplies, blood and blood derivatives, etc. are also covered. Outpatient hospital services include any of the above services which may be appropriately
provided on an outpatient or ambulatory basis (i.e., laboratory, radiology, therapies, ambulatory surgery, etc.). Observation services may be provided on an outpatient basis, if determined reasonable and necessary to decide whether the member should
be admitted for inpatient care. Observation services include the use of a bed and periodic monitoring by hospital nursing staff and/or other staff to evaluate, stabilize or treat medical conditions of a significant degree of instability and/or
disability. Refer to the AMPM for limitations on hospital stays. 
 Immunizations: The Contractor shall provide medically necessary
immunizations for adults 21 years of age and older. Refer to the AMPM for current immunization requirements. The Contractor is required to meet specific immunization rates for members under the age of 21, which are described in Section D, Paragraph
23, Quality Management and Performance Improvement. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

40 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Incontinence Briefs: In general, incontinence briefs (diapers) are not covered for members
unless medically necessary to treat a medical condition. However, for AHCCCS members over three years of age and under 21 years of age incontinence briefs, including pull-ups and incontinence pads, are also covered to prevent skin breakdown and to
enable participation in social community, therapeutic, and educational activities under limited circumstances. In addition, effective December 15, 2014 for members in the ALTCS Program who are 21 years of age and older, incontinence briefs,
including pull-ups and incontinence pads are also covered in order to prevent skin breakdown as outlined in AMPM Policy 310-P. See A.A.C. R9-22-212 and AMPM Chapters 300 and 400. 

Laboratory: Laboratory services for diagnostic, screening and monitoring purposes are covered when ordered by the member’s PCP, other
attending physician or dentist, and provided by a Clinical Laboratory Improvement Act (CLIA) approved free-standing laboratory or hospital laboratory, clinic, physician office or other health care facility laboratory. 

Upon written request, the Contractor may obtain laboratory test data on members from a laboratory or hospital- based laboratory subject to the requirements
specified in A.R.S. §36-2903(Q) and (R). The data shall be used exclusively for quality improvement activities and health care outcome studies required and/or approved by AHCCCS. 

Maternity: The Contractor shall provide pregnancy identification, prenatal care, treatment of pregnancy related conditions, labor and delivery
services, and postpartum care for members. Services may be provided by physicians, physician assistants, nurse practitioners, certified nurse midwives, or licensed midwives. Members may select or be assigned to a PCP specializing in obstetrics while
they are pregnant. Members anticipated to have a low-risk delivery, may elect to receive labor and delivery services in their home from their maternity provider, if this setting is included in the allowable settings for the Contractor, and the
Contractor has providers in its network that offer home labor and delivery services. Members anticipated to have a low-risk prenatal course and delivery may elect to receive maternity services of prenatal care, labor and delivery and postpartum care
provided by certified nurse midwives or licensed midwives, if they are in the Contractor’s provider network. Members receiving maternity services from a certified nurse midwife or a licensed midwife must also be assigned to a PCP for other
health care and medical services. A certified nurse midwife may provide those primary care services that they are willing to provide and that the member elects to receive from the certified nurse midwife. Members receiving care from a certified
nurse midwife may also elect to receive some or all her primary care from the assigned PCP. Licensed midwives may not provide any additional medical services as primary care is not within their scope of practice. Members who transition to a new
Contractor or become enrolled during their third trimester must be allowed to complete maternity care with their current AHCCCS registered provider, regardless of contractual status, to ensure continuity of care. 

The Contractor shall allow women and their newborns to receive up to 48 hours of inpatient hospital care after a routine vaginal delivery and up to 96 hours
of inpatient care after a cesarean delivery. The attending health care provider, in consultation with the mother, may discharge the mother or newborn prior to the minimum length of stay. A normal newborn may be granted an extended stay in the
hospital of birth when the mother’s continued stay in the hospital is beyond the 48 or 96 hour stay. 
 The Contractor shall inform all assigned AHCCCS
pregnant women of voluntary prenatal HIV/AIDS testing and the availability of medical counseling, if the test is positive. The Contractor shall provide information in the Member Handbook and annually in the member newsletter, to encourage pregnant
women to be tested and instructions about where to be tested. Semi-annually, the Contractor shall report to AHCCCS, Division of Health Care Management (DHCM) the number of pregnant women who have been identified as HIV/AIDS-positive for each quarter
during the contract year. This report is due as specified in Attachment F3, Contractor Chart of Deliverables. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

41 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Medical Foods: Medical foods are covered within limitations defined in the AMPM for members
diagnosed with a metabolic condition included under the ADHS Newborn Screening Program and as specified in the AMPM. The medical foods, including metabolic formula and modified low protein foods, must be prescribed or ordered under the supervision
of a physician. 
 Medical Supplies, Durable Medical Equipment (DME), and Prosthetic Devices: These services are covered when prescribed by
the member’s PCP, attending physician or practitioner, or by a dentist as described in the AMPM. Prosthetic devices must be medically necessary and meet criteria as described in the AMPM. For persons age 21 or older, AHCCCS will not pay for
microprocessor controlled lower limbs and microprocessor controlled joints for lower limbs. Medical equipment may be rented or purchased only if other sources are not available which provide the items at no cost. The total cost of the rental must
not exceed the purchase price of the item. Reasonable repairs or adjustments of purchased equipment are covered to make the equipment serviceable and/or when the repair cost is less than renting or purchasing another unit. 

Nursing Facility: The Contractor shall provide services in nursing facilities, including religious non-medical health care institutions, for
members who require short-term convalescent care not to exceed 90 days per contract year. In lieu of a nursing facility, the member may be placed in an assisted living facility, an alternative residential setting, or receive Home and Community Based
Services (HCBS) as defined in A.A.C. R9-22 Article 2 and A.A.C. R9-28 Article 2 that meet the provider standards described in A.A.C. R9-28 Article 5, and subject to the limitations set forth in the AMPM. 

Nursing facility services must be provided in a dually-certified Medicare/Medicaid nursing facility, which includes in the per-diem rate: nursing services;
basic patient care equipment and sickroom supplies; dietary services; administrative physician visits; non-customized DME; necessary maintenance and rehabilitation therapies; over-the-counter medications; social, recreational and spiritual
activities; and administrative, operational medical direction services. See Section D, Paragraph 41, Responsibility for Nursing Facility Reimbursement, for further details. 

The Contractor shall notify the Assistant Director of the Division of Member Services, by Email, when a member has been residing in a nursing facility,
alternative residential facility or receiving home and community based services for 45 days. This will allow AHCCCS time to follow-up on the status of the ALTCS application and to consider potential Fee-For-Service coverage, if the stay goes beyond
the 90 day per contract year maximum. The notice should be sent via e-mail to HealthPlan45DayNotice@azahcccs.gov. 
 Notifications must include: 

 

	a.	Member Name 

  

	b.	AHCCCS ID 

  

	c.	Date of Birth 

  

	d.	Name of Facility 

  

	e.	Admission Date to the Facility 

  

	f.	Date the member will reach the 90 days 

  

	g.	Name of Contractor of enrollment 

 Nutrition: Nutritional assessments are conducted as a part of
the EPSDT screenings for members under age 21, and to assist members 21 years of age and older whose health status may improve with over- and under- nutritional intervention. Assessment of nutritional status on a periodic basis may be provided as
determined necessary, and as a part of the health risk assessment and screening services provided by the member’s PCP. Assessments may also be provided by a registered dietitian when ordered by the member’s PCP. AHCCCS covers nutritional
therapy on an enteral, parenteral or oral basis, when determined medically necessary, according to the criteria specified in the AMPM, to provide either complete daily dietary requirements or to supplement a member’s daily nutritional and
caloric intake. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

42 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Oral Health: The Contractor shall provide all members under the age of 21 years with all
medically necessary dental services including emergency dental services, dental screening, preventive services, therapeutic services and dental appliances in accordance with the AHCCCS Dental Periodicity Schedule. The Contractor shall monitor
compliance with the AHCCCS Dental Periodicity Schedule for dental screening services. The Contractor must develop processes to assign members to a dental home by one year of age and communicate that assignment to the member. The Contractor must
regularly notify the oral health professional which members have been assigned to the provider’s dental home for routine preventative care as outlined in AMPM Chapter 400. The Contractor is required to meet specific utilization rates for
members as described in Section D, Paragraph 23, Quality Management and Performance Improvement. The Contractor shall ensure that members are notified in writing when dental screenings are due, if the member has not been scheduled for a visit. If a
dental screening is not received by the member, a second written notice must be sent. Members under the age of 21 may request dental services without referral and may choose a dental provider from the Contractor’s provider network. 

Pursuant to A.A.C. R9-22-207, for members who are 21 years of age and older, the Contractor shall cover medical and surgical services furnished by a dentist
only to the extent such services may be performed under State law either by a physician or by a dentist. These services would be considered physician services if furnished by a physician. Limited dental services are covered for pre-transplant
candidates and for members with cancer of the jaw, neck or head. See AMPM for specific details. 
 Orthotics: Orthotics are covered for AHCCCS
members under the age of 21 as outlined in AMPM Policy 430. Orthotics are covered for AHCCCS members 21 years of age and older if all of the following apply: 
  

	1.	The use of the orthotic is medically necessary as the preferred treatment option and consistent with Medicare guidelines; 

  

	2.	The orthotic is less expensive than all other treatment options or surgical procedures to treat the same diagnosed condition; and 

  

	3.	The orthotic is ordered by a physician or primary care practitioner. 

 Medical equipment may be rented or
purchased only if other sources, which provide the items at no cost, are not available. The total cost of the rental must not exceed the purchase price of the item. Reasonable repairs or adjustments of purchased equipment are covered for all members
over and under the age of 21 to make the equipment serviceable and/or when the repair cost is less than renting or purchasing another unit. The component will be replaced if at the time authorization is sought documentation is provided to establish
that the component is not operating effectively. 
 Physician: The Contractor shall provide physician services to include medical assessment,
treatments and surgical services provided by licensed allopathic or osteopathic physicians. 
 Post-stabilization Care Services: Pursuant to
A.A.C. R9-22-210 and 42 CFR 438.114, 422.113(c) and 422.133, the following conditions apply with respect to coverage and payment of emergency and of post-stabilization care services, except where otherwise noted in the contract: 

The Contractor must cover and pay for post-stabilization care services without authorization, regardless of whether the provider that furnishes the service
has a contract with the Contractor, for the following situations: 
  

	a.	Post-stabilization care services that were pre-approved by the Contractor; 

  

	b.	Post-stabilization care services were not pre-approved by the Contractor because the Contractor did not respond to the treating provider’s request for pre-approval within one hour after being requested to approve
such care or could not be contacted for pre-approval; 

  

	c.	The Contractor representative and the treating physician cannot reach agreement concerning the member’s care and a Contractor physician is not available for consultation. In this situation, the Contractor must give
the treating physician the opportunity to consult with a Contractor physician and the treating physician may continue with care of the patient until a Contractor physician is reached or one of the criteria in 42 CFR 422.113(c)(3) is met.



  
 Acute Care Contract 

10/01/2015 Renewal 
  

43 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Pursuant to 42 CFR 422.113(c)(3), the Contractor’s financial responsibility for post-stabilization care
services that have not been pre-approved ends when: 
  

	a.	A Contractor physician with privileges at the treating hospital assumes responsibility for the member’s care; 

  

	b.	A Contractor physician assumes responsibility for the member’s care through transfer; 

  

	c.	A Contractor representative and the treating physician reach an agreement concerning the member’s care; or 

  

	d.	The member is discharged. 

 Pregnancy Terminations: AHCCCS covers pregnancy termination if the
pregnant member suffers from a physical disorder, physical injury, or physical illness, including a life endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the member in
danger of death unless the pregnancy is terminated, or the pregnancy is a result of rape or incest. 
 The attending physician must acknowledge that a
pregnancy termination has been determined medically necessary by submitting the Certificate of Necessity for Pregnancy Termination. This certificate must be submitted to the Contractor’s Medical Director and meet the requirements specified in
the AMPM. The Certificate must certify that, in the physician’s professional judgment, the criteria have been met. 
 Prescription
Medications: Medications ordered by a PCP, attending physician, dentist or other authorized prescriber and dispensed under the direction of a licensed pharmacist are covered subject to limitations related to prescription supply amounts,
Contractor formularies and prior authorization requirements. An appropriate over-the-counter medication may be prescribed as defined in the AMPM when it is determined to be a lower-cost alternative to a prescription medication. 

Pharmaceutical Rebates: The Contractor, including the Contractor’s Pharmacy Benefit Manager (PBM), is prohibited from negotiating
any rebates with drug manufacturers for preferred or other pharmaceutical products when AHCCCS has a supplemental rebate contract for the product(s). A listing of products covered under supplemental rebate agreements will be available on the
AHCCCS website under the Pharmacy Information section. 
 If the Contractor or its PBM has an existing rebate agreement with a manufacturer,
all outpatient drug claims, including provider-administered drugs for which AHCCCS is obtaining supplemental rebates, must be exempt from such rebate agreements. For pharmacy related encounter data information Section D, Paragraph 65, Encounter Data
Reporting. 
 Medicare Part D: AHCCCS covers those drugs ordered by a PCP, attending physician, dentist or other authorized prescriber
and dispensed under the direction of a licensed pharmacist subject to limitations related to prescription supply amounts, and the Contractor’s prior authorization requirements if they are excluded from Medicare Part D coverage. Medications that
are covered by Part D, but are not on a specific Part D Health Plan’s formulary are not considered excluded drugs and will not be covered by AHCCCS. This applies to members who are enrolled in Medicare Part D or are eligible for Medicare Part
D. See AMPM Chapter 300, Section 310-V. 
 Primary Care Provider: Primary Care Provider (PCP) services are covered when provided by a
physician, physician assistant or nurse practitioner selected by, or assigned to, the member. The PCP provides primary health care and serves as a coordinator in referring the member for specialty medical services [42 CFR 438.208(b)]. The PCP is
responsible for maintaining the member’s primary medical record, which contains documentation of all health risk assessments and health care services of which they are aware whether or not they were provided by the PCP. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

44 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Radiology and Medical Imaging: These services are covered when ordered by the member’s
PCP, attending physician or dentist and are provided for diagnosis, prevention, treatment or assessment of a medical condition. 
 Rehabilitation
Therapy: The Contractor shall provide occupational, physical and speech therapies. Therapies must be prescribed by the member’s PCP or attending physician for an acute condition and the member must have the potential for improvement due
to the rehabilitation. 
 Occupational and Speech therapy is covered for all members receiving inpatient hospital (or nursing facility services).
Occupational Therapy and Speech therapy services provided on an outpatient basis are only covered for members under the age of 21. Physical Therapy is covered for all members in both inpatient and outpatient settings. Outpatient physical therapy for
members 21 years of age or older are subject to visit limits per contract year as described in the AMPM. 
 Respiratory Therapy: Respiratory
therapy is covered when prescribed by the member’s PCP or attending physician, and is necessary to restore, maintain or improve respiratory functioning. 

Transplantation of Organs and Tissue, and Related Immunosuppressant Drugs: These services are covered within limitations defined in the AMPM for
members diagnosed with specified medical conditions. Services include: pre-transplant inpatient or outpatient evaluation; donor search; organ/tissue harvesting or procurement; preparation and transplantation services; and convalescent care. In
addition, if a member receives a transplant covered by a source other than AHCCCS, medically necessary non-experimental services are provided, within limitations, after the discharge from the acute care hospitalization for the transplantation.
AHCCCS maintains specialty contracts with transplantation facility providers for the Contractor’s use or the Contractor may select its own transplantation provider. Refer to Section D, Paragraph 57, Reinsurance. 

Transportation: These services include emergency and non-emergency medically necessary transportation. Emergency transportation, including
transportation initiated by an emergency response system such as 911, may be provided by ground, air or water ambulance to manage an AHCCCS member’s emergency medical condition at an emergency scene and transport the member to the nearest
appropriate medical facility. Non-emergency transportation shall be provided for members who are unable to provide or secure their own transportation for medically necessary services using the appropriate mode based on the needs of the member. The
Contractor shall ensure that members have coordinated, reliable, medically necessary transportation to ensure members arrive on-time for regularly scheduled appointments and are picked up upon completion of the entire scheduled treatment. 

Triage/Screening and Evaluation: These are covered services when provided by an acute care hospital, an IHS or 638 tribal facility and
after-hours settings to determine whether or not an emergency exists, assess the severity of the member’s medical condition and determine services necessary to alleviate or stabilize the emergent condition. Triage/screening services must be
reasonable, cost effective and meet the criteria for severity of illness and intensity of service. 
 Vision Services/Ophthalmology/Optometry:
The Contractor shall provide all medically necessary emergency eye care, vision examinations, prescriptive lenses, frames, and treatments for conditions of the eye for all members under the age of 21. For members who are 21 years of age and older,
the Contractor shall provide emergency care for eye conditions which meet the definition of an emergency medical condition. Vision examinations and the provision of prescriptive lenses are covered for adults when medically necessary following
cataract removal. Medically necessary vision examinations and prescriptive lenses and frames are covered if required following cataract removal. Refer to AMPM Chapter 300. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

45 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Members shall have full freedom to choose, within the Contractor’s network, a practitioner in the field
of eye care, acting within the scope of their practice, to provide the examination, care or treatment for which the member is eligible. A “practitioner in the field of eye care” is defined to be either an ophthalmologist or an optometrist.

 Well Exams: Well visits, such as, but not limited to, well woman exams, breast exams, and prostate exams are covered for members 21 years
of age and older. For members under 21 years of age, AHCCCS continues to cover medically necessary services under the EPSDT Program. 
 ADULT DUAL
MEMBERS RECEIVING GENERAL MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES 
 Support Services (State Only): Support services including, but
not limited to, personal care services, prevention education, ongoing support to maintain employment, and supported housing, are provided by the Arizona Regional Behavioral Health Authorities (RBHAs) as outlined in the Covered Behavioral Health
Services Guide, to facilitate the delivery of or enhance the benefit received from other behavioral health services. The Contractor shall assist members with how to access support services and shall coordinate care for the member as appropriate.

 11. SPECIAL HEALTH CARE NEEDS 
 AHCCCS has specified
in its Quality Assessment and Performance Improvement Strategy certain populations with special health care needs as defined by the State [42 CFR 438.208(c)(1)].v

Members with special health care needs are those members who have serious and chronic physical, developmental, or behavioral conditions requiring medically
necessary health and related services of a type or amount beyond that required by members generally. A member will be considered as having special health care needs if the medical condition simultaneously meets the following criteria:vi 
  

	a.	Lasts or is expected to last one year or longer, and 

  

	b.	Requires ongoing care not generally provided by a primary care provider. 

 AHCCCS has determined that the
following populations meet this definition:vii 
  

	a.	Members who are recipients of services provided through the Children’s Rehabilitative Services (CRS) program 

  

	b.	Members who are recipients of services provided through the Arizona Department of Health Services Division of Behavioral Health contracted Regional Behavioral Health Authorities (RBHAs), and 


 

	c.	Members diagnosed with HIV/AIDS 

  

	d.	Arizona Long Term Care System: 

  

	 	•	 	Members enrolled in the ALTCS program who are elderly and/or have a physically disability, and 

  

	 	•	 	Members enrolled in the ALTCS program who have a developmental disability. 

 AHCCCS monitors quality and
appropriateness of care/services for routine and special health care needs members through annual Operational and Financial Reviews of Contractors and the review of required Contractor deliverables set forth in contract, program specific performance
measures, and performance improvement projects.viii 
 The Contractor shall have in place a mechanism
to identify all members with special health care needs [42 CFR 438.240(b)(4)]. The Contractor shall implement mechanisms to assess each member identified as having special health care needs, in order to identify any ongoing special conditions of the
member which require a course of treatment, regular care monitoring, or transition to another AHCCCS program. The assessment mechanisms shall use appropriate health care professionals [42 CFR 438.208(c)(2)]. The Contractor shall share with other
entities providing services to the member the results of its identification and assessment of that member’s needs so that those activities need not be duplicated [42 CFR 438.208(b)(3)]. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

46 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 For members with special health care needs determined to need a specialized course of treatment or regular
care monitoring, the Contractor must have procedures in place to allow members to directly access a specialist (for example through a standing referral or an approved number of visits) as appropriate for the member’s condition and identified
needs [42 CFR 438.208(c)(4)]. For members transitioning, see Section D, Paragraph 9, Transition Activities. 
 The Contractor shall have a methodology to
identify providers willing to provide medical home services and make reasonable efforts to offer access to these providers. 
 The American Academy of
Pediatrics (AAP) describes care from a medical home as: 
  

	 	•	 	Accessible 

  

	 	•	 	Continuous 

  

	 	•	 	Coordinated 

  

	 	•	 	Family-centered 

  

	 	•	 	Comprehensive 

  

	 	•	 	Compassionate 

  

	 	•	 	Culturally effective 

 The Contractor shall ensure that populations with ongoing medical needs, including but
not limited to dialysis, radiation and chemotherapy, have coordinated, reliable, medically necessary transportation to ensure members arrive on-time for regularly scheduled appointments and are picked up upon completion of the entire scheduled
treatment. See Section D, Paragraph 33, Appointment Standards. 
 12. BEHAVIORAL HEALTH SERVICES 

With the exception of adult dual members receiving general mental health and substance abuse services as referenced below, AHCCCS members enrolled with an
Acute Care Contractor receive behavioral health services through a Regional Behavioral Health Authority (RBHA) or for American Indians, through a Tribal/Regional Behavioral Health Authority (T/RBHA) or IHS or 638 tribal facility. Behavioral health
services include but are not limited to screening, treatment and assistance in coordinating care between the acute and behavioral health providers. 
 For
all enrolled members, the Contractor is responsible for the following: 
 SMI Eligibility: For TXIX eligible adults enrolled with the
Contractor who are later determined to have a Serious Mental Illness (SMI), the member shall be transitioned to an Integrated RBHA as outlined in Paragraph 3, Enrollment and Disenrollment. The Integrated RBHA will provide the full continuum of care
including all physical and behavioral health care as well as supportive services, such as peer and family support, patient education, engagement and follow up.

Member Education: The Contractor shall be responsible for including information in the Member Handbook and other materials to inform members how
to access covered behavioral health services. Materials shall include, but not be limited to, information about behavioral health conditions that may be treated by a Primary Care Provider (PCP) which includes anxiety, depression and ADHD. Refer to
the AMPM for covered behavioral health services. 
 Referrals: Members may self–refer to the T/RBHA system for screening, evaluation or
treatment or be referred by schools, State agencies, providers, or other parties. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

47 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 EPSDT: As specified in Section D, Paragraph 10, Scope of Services, EPSDT, the Contractor must
provide behavioral health screenings for members under 21 years of age in compliance with the AHCCCS EPSDT Periodicity Schedule. The Contractor shall initiate and coordinate behavioral health referrals to the T/RBHA or appropriate behavioral health
provider when determined necessary. 
 Emergency Services: When members present in an emergency room setting, the Contractor is responsible
for payment of all emergency room services and transportation for all members regardless of the principal diagnosis on the emergency room and/or transportation claim. In addition to those emergency services listed above, the Contractor is
responsible for payment of the associated professional services when the principal diagnosis on the claim is physical health, as delineated in ACOM Policy 432. 

Coordination of Care: For members assigned to a T/RBHA, the Contractor shall meet with the T/RBHAs to improve and address coordination of care
issues. The Contractor shall ensure that information and training is available to PCPs regarding behavioral health coordination of care processes. The Contractor shall establish policies and procedures for coordination of care and shall describe
them in its provider manual. Policies for referral must include, at a minimum, criteria, processes, responsible parties and minimum requirements no less stringent than those specified in this contract for the forwarding of member medical
information. 
 The Contractor shall ensure that its quality management program incorporates monitoring of the PCP’s management of behavioral health
disorders, coordination of care with, and transfer of care to T/RBHA providers as required under this contract. 
 Medical Records: The
Contractor is responsible for ensuring that a medical record is established by the PCP when behavioral health information is received from the T/RBHA or the behavioral health provider about a member assigned to the PCP even if the PCP has not yet
seen the assigned member. In lieu of establishing a medical record, the information may be kept in an appropriately labeled file but must be associated with the member’s medical record as soon as one is established. 

Sharing of Data: On a recurring basis (no less than quarterly based on adjudication date), AHCCCS shall provide the Contractor an electronic
file of claims and encounter data for members enrolled with the Contractor who have received services, during the member’s enrollment period, from another contractor or through AHCCCS FFS for purposes of member care coordination. Data sharing
will comply with Federal privacy regulations. 
 Sharing of Records: The Contractor shall within 10 business days of receiving the request,
require the PCP to coordinate care and respond to T/RBHA and/or behavioral health provider information requests pertaining to members receiving services through the behavioral health system. The response should include, but is not limited to,
current diagnoses, medications, laboratory results, most recent PCP visit, and information about recent hospital and emergency room visits. The Contractor will ensure coordination of referrals and follow-up collaboration, as necessary, for members
identified by the behavioral health provider as needing acute care services. For guidance in addressing the needs of members with multi system involvement and complex behavioral health and co-occurring conditions, refer to AMPM Policy 570, Community
Collaborative Care Teams. 
 Arizona State Hospital: For enrolled members who are inpatient at the Arizona State Hospital (AzSH), the
Contractor is required to follow ACOM Policy 432 and AMPM Policy 1020 regarding medical care coordination for these members. 
 Home Health
Services: In the event that a member’s mental health status renders them incapable or unwilling to manage their medical condition and the member has a skilled medical need, the Contractor must arrange ongoing medically necessary nursing
services. The Contractor shall also have a mechanism in place for tracking members for whom ongoing medically necessary services are required. This service shall be provided under the direction of a physician to prevent hospitalization or
institutionalization and may include nursing, therapies, supplies and 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

48 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 
home health aide services. It shall be provided on a part-time or intermittent basis. The Contractor is prohibited from paying for an item or service (other than an emergency item or
service, not including items or services furnished in an emergency room of a hospital) for home health care services provided by an agency or organization, unless AHCCCS Provider Registration verifies compliance with the surety bond requirements
specified in Sections 1861(o)(7) and 1903(i)(18) of the Social Security Act.ix 
 Medication
Management Services: The Contractor shall allow PCPs to treat members diagnosed with anxiety, depression and Attention Deficit Hyperactivity Disorder (ADHD). For purposes of medication management, it is not required that the PCP be the
member’s assigned PCP. PCPs who treat members with these behavioral health conditions may provide medication management services including prescriptions, laboratory and other diagnostic tests necessary for diagnosis, and treatment. The
Contractor shall make available, on the Contractor’s formulary, medications for the treatment of these disorders. The Contractor is responsible for these services both in the prospective and prior period coverage timeframes. 

Tool Kits: Clinical tool kits for the treatment of anxiety, depression, and ADHD are available in the AMPM. These tool kits are a resource only
and may not apply to all patients and all clinical situations. The tool kits are not intended to replace clinical judgment. The Contractor shall ensure that PCPs who have an interest or are actively treating members with these disorders are aware of
these resources and/or are utilizing other recognized, clinical tools/evidence-based guidelines. The Contractor shall develop a monitoring process to ensure that PCPs utilize evidence-based guidelines/recognized clinical tools when prescribing
medications to treat depression, anxiety, and ADHD. 
 Step Therapy: The Contractor may implement step therapy for behavioral health
medications used for treating anxiety, depression and ADHD disorders. The Contractor shall provide education and training for providers regarding the concept of step therapy. If the T/RBHA/behavioral health provider provides documentation to the
Contractor that step therapy has already been completed for the conditions of anxiety, depression or ADHD, or that step therapy is medically contraindicated, the Contractor shall continue to provide the medication at the dosage at which the member
has been stabilized by the behavioral health provider. In the event the PCP identifies a change in the member’s condition, the PCP may utilize step therapy until the member is stabilized for the condition of anxiety, depression or ADHD. The
Contractor shall monitor PCPs to ensure that they prescribe medication at the dosage at which the member has been stabilized. 
 Access to
Services: For member assigned to a T/RBHA, the Contractor is responsible for providing transportation to a member’s first T/RBHA evaluation appointment if the member is unable to provide their own transportation. The Contractor shall be
responsible for meeting the appointment standards found in Section D, Paragraph 33, Appointment Standards. 
 Transfer of Care: When a PCP has
initiated medication management services for a member to treat a behavioral health disorder, and it is subsequently determined by the PCP that the member should be transferred to a T/RBHA/ behavioral health provider for evaluation and/or continued
medication management services, the Contractor shall require and ensure that the PCP coordinates the transfer of care. All affected subcontracts shall include this provision. 

For members assigned to a T/RBHA, the Contractor shall establish policies and procedures for the transition of members to the T/RBHA for ongoing treatment.
The Contractor shall ensure that PCPs maintain continuity of care for these members. 
 The policies and procedures must address, at a minimum, the
following: 
  

	1.	Guidelines for when a transition of the member to the T/RBHA for ongoing treatment is indicated; 

  

	2.	Protocols for notifying the T/RBHA of the member’s transfer, including reason for transfer, diagnostic information, and medication history; 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

49 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	3.	Protocols and guidelines for the transfer or sharing of medical records information and protocols for responding to T/RBHA requests for additional medical record information; 


 

	4.	Protocols for transition of prescription services, including but not limited to notification to the T/RBHA of the member’s current medications and timeframes for dispensing and refilling medications during the
transition period. This coordination must ensure at a minimum, that the member does not run out of prescribed medications prior to the first appointment with a T/RBHA prescriber and that all relevant member medical information including the reason
for transfer is forwarded to the receiving T/RBHA prescriber prior to the member’s first scheduled appointment with the T/RBHA prescriber; and 

  

	5.	Contractor monitoring activities to ensure that members are appropriately transitioned to the T/RBHA for care. 


Integrated Services: The Contractor is encouraged to develop specific strategies to promote care integration activities. These strategies may
include but are not limited to contracting with T/RBHAs or behavioral health providers as well as establishing integrated settings which serve members’ primary care and behavioral health needs. The Contractor should consider the behavioral
health needs, in addition to the primary health care needs, of members during network development to improve member access to care, care coordination and to reduce duplication of services. 

ADULT DUAL MEMBERS RECEIVING GENERAL MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES 

Effective, October 1, 2015, AHCCCS dual members 18 years of age and older who are receiving general mental health and substance abuse services and who are
enrolled with the Contractor will receive behavioral health services through the Contractor. Prior to October 1, 2015, these services were provided through a T/RBHA. Choices for American Indian members are described in Section D, Paragraph 3,
Enrollment and Disenrollment. 
 Behavioral Health services are described in detail in the Covered Behavioral Health Services Guide and the AMPM. Covered
services include: 
  

	1.	Behavior Management (personal care, family support/home care training, peer support) 

  

	2.	Behavioral Health Case Management Services (with limitations) 

  

	3.	Behavioral Health Nursing Services 

  

	4.	Emergency Behavioral Health Care 

  

	5.	Emergency and Non-Emergency Transportation 

  

	6.	Evaluation and Assessment 

  

	7.	Individual, Group and Family Therapy and Counseling 

  

	8.	Inpatient Hospital Services - (Contractors may provide services in alternative inpatient settings that are licensed by ADHS/DLS, in lieu of services in an inpatient hospital. These alternative settings must be lower
cost than traditional inpatient settings. 

  

	9.	Behavioral Health Inpatient Facilities 

  

	10.	Laboratory and Radiology Services for Psychotropic Medication Regulation and Diagnosis 

  

	11.	Opioid Agonist Treatment 

  

	12.	Partial Care (Supervised day program, therapeutic day program and medical day program) 

  

	13.	Psychosocial Rehabilitation (living skills training; health promotion; supportive employment services) 

  

	14.	Psychotropic Medication 

  

	15.	Psychotropic Medication Adjustment and Monitoring 

  

	16.	Respite Care (with limitations) 

  

	17.	Substance Abuse Transitional Facility Services 

  

	18.	Screening 

  

	19.	Home Care Training to Home Care Client 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

50 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 The Contractor shall ensure that all behavioral health services provided are medically necessary as
determined by a qualified behavioral health professional. Psychiatrists, psychologists, physician assistants, certified psychiatric nurse practitioners, licensed clinical social workers, licensed professional counselors, licensed marriage and family
therapists and licensed independent substance abuse counselors may bill independently. Other behavioral health professionals must be employed by or contracted with and bill through an AHCCCS registered behavioral health provider. 

The Contractor’s network shall include Master’s level and doctoral trained clinicians in the fields of social work, counseling, and psychology that
are trained in implementation of best practices for medically and behaviorally complex conditions such as intellectual/cognitive disabilities, trauma related disorders, substance abuse, sexual disorders, and special age groups such as transition age
youth and members aged birth to five years old. 
 Behavioral health needs shall be assessed and services provided in collaboration with the member, the
member’s family and all others involved in the member’s care, including other agencies or systems. Services shall be accessible and provided by competent individuals who are adequately trained and supervised. The strengths and needs of the
member and their family shall determine the types and intensity of services. Services should be provided in a manner that respects the member and family’s cultural heritage and appropriately utilizes natural supports in the member’s
community. 
 Transition: Transition of members for behavioral health services provided through the Contractor will occur under two
circumstances: 
  

	1.	Members who are dually eligible will be transitioned to the Contractor to receive their behavioral health services when turning 18 years of age and have a change in behavioral health category from ‘child’ to
‘general mental health/substance abuse’. 

  

	2.	Members who have a behavioral health category of ‘general mental health/substance abuse’ will be transitioned to the Contractor to receive their behavioral health services when they become dually eligible.


 SMI Eligibility Evaluation and Determination: Payment for evaluations for adult dual members who are receiving general mental
health and substance abuse services conducted for the purpose of an SMI determination is the responsibility of the Contractor. The Contractor shall ensure evaluations are sent to the Crisis Response Network (CRN) which conducts all SMI eligibility
determinations statewide. 
 Referrals: The Contractor shall develop, monitor and continually evaluate its processes for timely referral,
evaluation and treatment planning for behavioral health services. Requests for behavioral health services made by the member, family, guardian, or any health care professional shall be assessed by the Contractor for appropriateness within three
business days of the request. If it is determined services are needed, a referral for evaluation shall be made within one business day and the initial appointment shall be secured in accordance with appointment standards. See Paragraph 33,
Appointment Standards. 
 Emergency Services: When members present in an emergency room setting, the Contractor is responsible for payment of
all emergency room services and transportation for all members regardless of the principal diagnosis on the emergency room and/or transportation claim. In addition to those emergency services listed above, the Contractor is responsible for payment
of the associated professional services regardless of the principal diagnosis on the claim, as delineated in ACOM Policy 432. 
 Crisis
Services: Crisis services shall be community based, recovery-oriented, and member focused and shall work to stabilize individuals as quickly as possible to assist them in returning to their baseline of functioning. The Regional Behavioral
Health Authorities (RBHAs) within the Contractor’s geographic service area(s) are responsible for the delivery of timely crisis services, including telephone, community-based mobile, and facility-based stabilization (including observation not
to exceed 24 hours). See Covered Behavioral Health Services Guide, Section II. E. The RBHAs are responsible for notifying the Contractor within 24 hours of a member engaging in crisis services so subsequent services can be initiated by the
Contractor. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

51 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 The Contractor is responsible for all other medically necessary services related to a crisis episode. The
Contractor shall develop policies and procedures to ensure timely communication with RBHAs for members that have engaged crisis services. The Contractor shall ensure timely follow up and care coordination for members after receiving crisis services,
whether the member received services within, or outside the Contractor’s GSA at the time services were provided, to ensure stabilization of the member and appropriate delivery of ongoing necessary treatment and services. 

The Contractor shall: 
  

	1.	Assess the individual‘s needs, identify the supports and services that are necessary to meet those needs, and connect the individual to appropriate services; 


 

	2.	Provide solution-focused and recovery-oriented interventions designed to avoid unnecessary hospitalization, incarceration, or placement in a more segregated setting; and 


 

	3.	Utilize the engagement of peer and family support services in providing crisis services. 

 The Contractor shall
develop policies that outline its role and responsibility related to the treatment of individuals who are unable or unwilling to consent to treatment. The policy must be submitted for review as specified in Attachment F3, Contractor Chart of
Deliverables. The policy must address: 
  

	a.	Involuntary evaluation/petitioning 

  

	b.	Court ordered process, including tracking the status of court orders 

  

	c.	Execution of court order, and 

  

	d.	Judicial review 

 Court Ordered Treatment: The Contractor shall develop a collaborative process
with the counties to ensure coordination of care and information sharing for timely access to court ordered evaluation services and treatment. Reimbursement for court ordered screening and evaluation services are the responsibility of the County
pursuant to A.R.S. §36-545. Refer to ACOM Policy 437 for clarification regarding financial responsibility for the provision of medically necessary behavioral health services rendered after the completion of a court ordered evaluation, and ACOM
Policy 423 for clarification regarding the financial responsibility for the provision of specific mental health treatment/care when such treatment is ordered as a result of a judicial ruling. For additional information regarding behavioral health
services refer to Title 9 Chapter 22 Articles 2 and 12. 
 Community Service Agencies: The Contractor may contract with community service
agencies that are TXIX certified by ADHS for the delivery of covered behavioral health services. Refer to the AHCCCS Behavioral Health Service Delivery Information, available on the AHCCCS website, for more information and limitations. 

Monitoring, Training and Education: The Contractor is responsible for training the Behavioral Health Coordinator/staff and providers to identify
and screen for members’ behavioral health needs. At a minimum, training shall include information regarding covered behavioral health services, how to access them, including the petitioning process, how to involve the member and their family in
decision-making and service planning, and information regarding initial and quarterly behavioral health consultation requirements. Training for Behavioral Health Coordinator/staff and providers may be provided through employee orientation, clinical
in-services and/or information sharing via newsletters, brochures, etc. Training must be provided in sufficient detail and frequency to ensure that case managers and providers appropriately identify and refer members with behavioral health needs.
The Contractor shall maintain documentation of the behavioral health trainings in accordance with AMPM Policy 310. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

52 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 13. AHCCCS GUIDELINES, POLICIES AND MANUALS 

All AHCCCS guidelines, policies and manuals, including but not limited to, ACOM, AMPM, Reporting Guides, and Manuals are hereby incorporated by reference into
this contract. Guidelines, policies and manuals are available on the AHCCCS website. The Contractor is responsible for ensuring that its subcontractors are notified when modifications are made to the AHCCCS guidelines, policies, and manuals. The
Contractor is responsible for complying with all requirements set forth in these sources as well as with any updates. In addition, linkages to AHCCCS rules, statutes and other resources are available through the AHCCCS website. Upon adoption by
AHCCCS, updates will be available on the AHCCCS website. 
 14. MEDICAID SCHOOL BASED CLAIMING 

Pursuant to an Intergovernmental Agreement with the Department of Education, and a contract with a Third Party Administrator, AHCCCS pays participating school
districts for specifically identified Medicaid services when provided to Medicaid eligible children who are included under the Individuals with Disabilities Education Act (IDEA). The Medicaid services must be identified in the member’s
Individual Education Plan (IEP) as medically necessary for the child to obtain a public school education. See AMPM Chapter 700. 
 Medicaid School Based
(MSB) services are provided in a school setting or other approved setting specifically to allow children to receive a public school education. They do not replace medically necessary services provided outside the school setting or other MSB approved
alternative setting. Currently, services include audiology, therapies (OT, PT and speech/language); behavioral health evaluation and counseling; nursing and attendant care (health aid services provided in the classroom); and specialized
transportation to and from school on days when the child receives an AHCCCS-covered MSB service. 
 The Contractor’s evaluations and determinations of
medical necessity shall be made independent of the fact that the child is receiving MSB services. If a request is made for services that also are covered under the MSB program for a child enrolled with the Contractor, the request shall be evaluated
on the same basis as any request for a covered service. 
 The Contractor and its providers should coordinate with schools and school districts that provide
MSB services to the Contractor’s enrolled members. Services should not be duplicative. Contractor case managers, working with special needs children, should coordinate with the appropriate school staff working with these members. Transfer of
member medical information and progress toward treatment goals between the Contractor and the member’s school or school district is required as appropriate and should be used to enhance the services provided to members. 

15. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM 

Through the Vaccines for Children (VFC) program, the Federal and State governments purchase, and make available to providers at no cost, vaccines for AHCCCS
children under age 19. The Contractor shall not utilize AHCCCS funding to purchase vaccines for members under the age of 19. If vaccines are not available through the VFC program, the Contractor shall contact the AHCCCS Division of Health Care
Management, Clinical Quality Management for guidance. Any provider licensed by the State to administer immunizations, may register with Arizona Department of Health Services (ADHS) as a VFC provider to receive these free vaccines. The Contractor
shall not reimburse providers for the administration of the vaccines in excess of the maximum allowable as set by CMS. The Contractor shall comply with all VFC requirements and monitor contracted providers to ensure that physicians are registered as
VFC providers when acting as Primary Care Providers (PCP) for members under the age of 19 years. 
 Due to low numbers of children in their panels providers
in certain Geographic Service Areas (GSAs) may choose not to provide vaccinations. Whenever possible, members should be assigned to VFC registered providers within the same or a nearby community. When that is not possible, the Contractor must
develop processes to ensure vaccinations are available through a VFC enrolled provider or through the appropriate County Health Department. In all instances, the vaccines are to be provided through the VFC program. The Contractor must develop
processes to pay the administration fee to whoever administers the vaccine regardless of their contract status with the Contractor. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

53 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Arizona State law requires the reporting of all immunizations given to children under the age of 19.
Immunizations must be reported at least monthly to the ADHS Immunization Registry. Reported immunizations are held in a central database known as ASIIS (Arizona State Immunization Information System), which can be accessed by providers to obtain
complete, accurate immunization records. Software is available from ADHS to assist providers in meeting this reporting requirement. The Contractor must educate its provider network about these reporting requirements and the use of this resource.

 16. STAFF REQUIREMENTS AND SUPPORT SERVICES 
 The
Contractor shall have in place the organizational, operational, managerial and administrative systems capable of fulfilling all contract requirements. For the purposes of this contract, the Contractor shall not employ or contract with any individual
who has been debarred, suspended or otherwise lawfully prohibited from participating in any public procurement activity or from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under
guidelines implementing Executive Order 12549 [42 CFR 438.610 (a) & (b), 42 CFR 1001.1901(b), 42 CFR 1003.102(a)(2)]. The Contractor is obligated to screen employees and subcontractors to determine whether they have been excluded from
participation in Federal health care programs as outlined in Section D, Paragraph 62, Corporate Compliance. 
 The Contractor must employ sufficient staff
and utilize appropriate resources to achieve contractual compliance. The Contractor’s resource allocation must be adequate to achieve outcomes in all functional areas within the organization. Adequacy will be evaluated based on outcomes and
compliance with contractual and AHCCCS policy requirements. If the Contractor does not achieve the desired outcomes or maintain compliance with contractual obligations, additional monitoring and regulatory action may be employed by AHCCCS. This
action may include, but is not limited to, requiring the Contractor to hire additional staff and actions specified in Section D, Paragraph 72, Sanctions. 

The Contractor shall have local staff available 24 hours per day, seven days per week to work with AHCCCS and/or other State agencies, such as Arizona
Department of Health Services/Office of Licensure, on urgent issue resolutions. Urgent issue resolutions include Immediate Jeopardies (IJ), fires, or other public emergency situations. These staff shall have access to information necessary to
identify members who may be at risk and their current health/service status, the ability to initiate new placements/services, and have the ability to perform status checks at affected facilities and perform ongoing monitoring, if necessary. The
Contractor shall supply AHCCCS, Clinical Quality Management (CQM) with the contact information for these staff, as specified in Attachment F3, Contractor Chart of Deliverables. At a minimum the contact information shall include a current 24/7
telephone number. CQM must be notified and provided back up contact information when the primary contact person will be unavailable. 
 For functions not
required to be in State, the Contractor must notify AHCCCS as specified in Attachment F3, Contractor Chart of Deliverables, prior to moving functions outside the State of Arizona. The notification must include an implementation plan for the
transition. 
 The Contractor shall be responsible for costs associated with on-site audits or other oversight activities which result when functions are
located outside of the State of Arizona. 
 An individual staff member is limited to occupying a maximum of two of the Key Staff positions listed below,
unless prior approval is obtained by AHCCCS, Division of Health Care Management (DHCM). When submitting its functional organizational chart, as specified in Attachment F3, Contractor Chart of Deliverables, the Contractor must document, for each Key
Staff position, the portion of time allocated to each Medicaid contract as well as all other lines of business. The Contractor shall also inform AHCCCS DHCM in writing as specified in Attachment F3, Contractor Chart of Deliverables, when an employee
leaves one of the Key Staff  

  
 Acute Care Contract 

10/01/2015 Renewal 
  

54 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 
positions listed below. The name of the interim contact person should be included with the notification. The name and resume of the permanent employee should be submitted as soon as the new hire
has taken place along with a revised Organization Chart complete with Key Staff. If, at any point, the Contractor fails to maintain compliance with contractual obligations, AHCCCS reserves the right to evaluate staffing allocations and require
staffing enhancements in order to ensure adherence to established requirements. 
 At a minimum, the following staff is required: 

Key Staff Positions 
  

	a.	Administrator/CEO/COO who is located in Arizona, oversees the entire operation of the Contractor, and have the authority to direct and prioritize work, regardless of where performed. 


 

	b.	Medical Director/CMO who is located in Arizona and who is an Arizona-licensed physician in good standing. The Medical Director shall be actively involved in all major clinical programs and Quality Management and
Medical Management components of the Contractor. The Medical Director shall ensure timely medical decisions, including after-hours consultation as needed (see Section D, Paragraph 27, Network Development). 


 

	c.	Chief Financial Officer/CFO who is available to fulfill the responsibilities of the position and to oversee the budget, accounting systems, and financial reporting implemented by the Contractor.


  

	d.	Pharmacy Director/Coordinator who is an Arizona licensed pharmacist or physician who oversees and administers the prescription drug and pharmacy benefits. The Pharmacy Coordinator/Director may be an employee or
Contractor of the Plan. 

  

	e.	Dental Director must be an Arizona licensed general or pediatric dentist in good standing who is located in Arizona and is responsible for leading and coordinating the dental activities of the Contractor
including review and denial of dental services, provider consultation, utilization review, and participation in tracking and trending of quality of care issues as related to dental services. The Dental Director must provide required communication
between the Contractor and AHCCCS. The Dental Director may be an employee or Contractor of the plan but may not be from the Contractor’s delegated dental subcontractor. 


 

	f.	Corporate Compliance Officer who is located in Arizona and who will implement and oversee the Contractor’s compliance program. The Corporate Compliance Officer shall be a management official, available to
all employees, with designated and recognized authority to access records and make independent referrals to the AHCCCS Office of the Inspector General. See Section D, Paragraph 62, Corporate Compliance. 


 

	g.	Dispute and Appeal Manager who is responsible for managing and adjudicating member grievances and appeals, and provider claim disputes, arising under the Grievance System and for forwarding all requests for
hearing to AHCCCS Office of Administrative Legal Services (OALS) with the requested information. The Dispute and Appeal Manager and any staff under this position who manage and adjudicate disputes and appeals must be located in Arizona. See Section
D, Paragraph 26, Grievance System. 

  

	h.	Business Continuity Planning Coordinator as noted in ACOM Policy 104. 

  

	i.	Contract Compliance Officer who is located in Arizona and who will serve as the primary point-of-contact for all Contractor operational issues. The primary functions of the Contract Compliance Officer may include
but are not limited to coordinate the tracking and submission of all contract deliverables, fielding and coordinating responses to AHCCCS inquiries, and coordinating the preparation and execution of contract requirements such as Operational and
Financial Reviews (OFRs), random and periodic audits and ad hoc visits. 

  

	j.	Quality Management Manager who is an Arizona-licensed registered nurse, physician or physician’s assistant or a Certified Professional in Healthcare Quality (CPHQ) by the National Association for Health Care
Quality (NAHQ) and/or Certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Providers. The QM Manager must be located in Arizona and have experience in quality management and
quality improvement. Sufficient local staffing to meet the AHCCCS quality management contractual and policy requirements must also be in place. Staff must report directly to the Quality Management Manager. The primary functions of the Quality
Management Manager position are: 

  

	 	•	 	Ensure individual and systemic quality of care 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

55 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	 	•	 	Conduct comprehensive quality-of-care investigations 

  

	 	•	 	Conduct onsite quality management visits/reviews 

  

	 	•	 	Conduct Care Needed Today/Immediate Jeopardy investigations 

  

	 	•	 	Integrate quality throughout the organization 

  

	 	•	 	Implement process improvement 

  

	 	•	 	Resolve, track and trend quality of care grievances 

  

	 	•	 	Ensure a credentialed provider network 

  

	k.	Performance/Quality Improvement Coordinator who is located in Arizona and who has a minimum qualification as a CPHQ or CHCQM or comparable education and experience in health plan data and outcomes measurement.
Any staff under this position must be sufficient to meet the AHCCCS quality improvement contractual and policy requirements and must be located in Arizona. The primary functions of the Performance/Quality Improvement Coordinator are:


  

	 	•	 	Focus organizational efforts on improving clinical quality performance measures 

  

	 	•	 	Develop and implement performance improvement projects 

  

	 	•	 	Utilize data to develop intervention strategies to improve outcomes 

  

	 	•	 	Report quality improvement/performance outcomes 

  

	l.	Maternal Child Health/EPSDT Coordinator who is located in Arizona and who is an Arizona licensed nurse, physician or physician’s assistant; or has a Master’s degree in health services, public health,
health care administration or other related field, and/or a CPHQ or CHCQM certification. Any staff under this position must be sufficient to meet the AHCCCS MCH/EPSDT contractual and policy requirements and must be located in Arizona. Maternal Child
Health (MCH)/EPSDT staff must either report directly to the MCH/EPSDT Coordinator or the MCH/EPSDT Coordinator must have sufficient ability to ensure that AHCCCS MCH/EPSDT requirements are met. Sufficient local staffing under this position must be
in place to meet quality and performance measure goals. The primary functions of the MCH/EPSDT Coordinator are: 

  

	 	•	 	Ensure receipt of EPSDT services 

  

	 	•	 	Ensure receipt of maternal and postpartum care 

  

	 	•	 	Promote family planning services 

  

	 	•	 	Promote preventive health strategies 

  

	 	•	 	Identify and coordinate assistance for identified member needs 

  

	 	•	 	Interface with community partners 

  

	m.	Medical Management Manager who is an Arizona licensed registered nurse, physician or physician’s assistant if required to make medical necessity determinations; or have a Master’s degree in health
services, health care administration, or business administration if not required to make medical necessity determinations. This position is located in Arizona and manages all required medical management requirements under AHCCCS policies, rules, and
contract. Sufficient local staffing under this position must be in place to meet medical management requirements. The primary functions of the Medical Management Manager are: 


 

	 	•	 	Ensure adoption and consistent application of appropriate inpatient and outpatient medical necessity criteria 

  

	 	•	 	Ensure appropriate concurrent review and discharge planning of inpatient stays is conducted 

  

	 	•	 	Develop, implement and monitor the provision of care coordination, disease management and case management functions 

  

	 	•	 	Monitor, analyze and implement appropriate interventions based on utilization data, including identifying and correcting over or under utilization of services 


 

	 	•	 	Monitor prior authorization functions and assure that decisions are made in a consistent manner based on clinical criteria and meet timeliness standards 


 

	n.	Behavioral Health Coordinator who is a behavioral health professional as described in Health Services Rule A.A.C. R9-10-101, and is located in Arizona. The Behavioral Health Coordinator shall ensure AHCCCS
behavioral health requirements are implemented. The primary functions of the Behavioral Health Coordinator are: 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

56 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	 	•	 	Coordinate member behavioral care needs including active involvement in all out of state placement decisions 

  

	 	•	 	Develop processes to review and enhance network to reduce out of state placements 

  

	 	•	 	Develop processes to coordinate behavioral health care and physical health care between all providers 

  

	 	•	 	Participate in the identification of best practices for behavioral health services 

  

	 	•	 	Coordinate and liaise for American Indians who exercise choice options regarding behavioral health 

  

	o.	Member Services Manager who shall coordinate communications with members; serve in the role of member advocate; coordinate issues with appropriate areas within the organization; resolve member inquiries/problems
and meet standards for resolution, telephone abandonment rates and telephone hold times. 

  

	p.	Provider Services Manager who coordinates communications between the Contractor and its subcontractors and providers. This position is located in Arizona and ensures that providers receive prompt resolution to
their problems or inquiries, appropriate education about participation in the AHCCCS program and maintain a sufficient provider network. Sufficient local staffing under this position must be in place to ensure appropriate provider responsiveness.


  

	q.	Claims Administrator who shall ensure prompt and accurate provider claims processing. The primary functions of the Claims Administrator are: 


 

	 	•	 	Develop and implement claims processing systems capable of paying claims in accordance with State and Federal requirements 

  

	 	•	 	Develop processes for cost avoidance 

  

	 	•	 	Ensure minimization of claims recoupments 

  

	 	•	 	Meet claims processing timelines 

  

	 	•	 	Meet AHCCCS encounter reporting requirements 

  

	r.	Provider Claims Educator who is located in Arizona and facilitates the exchange of information between the grievance, claims processing, and provider relations systems. The primary functions of the Provider
Claims Educator are: 

  

	 	•	 	Educate contracted and non-contracted providers (i.e., professional and institutional) regarding appropriate claims submission requirements, coding updates, electronic claims transactions and electronic fund transfer,
and available Contractor resources such as provider manuals, website, fee schedules, etc. 

  

	 	•	 	Interface with the Contractor’s call center to compile, analyze, and disseminate information from provider calls 

  

	 	•	 	Identify trends and guides the development and implementation of strategies to improve provider satisfaction. Frequently communicate (i.e.: telephonic and on-site) with providers to assure the effective exchange of
information and gain feedback regarding the extent to which providers are informed about appropriate claims submission practices 

  

	s.	Information Systems (IS) Administrator who is responsible for information system management including coordination of the technical aspects of application infrastructure, server and storage needs, reliability and
survivability of all data and data exchange elements. 

  

	t.	MSA Administrator who is responsible for oversight of the Management Services Agreement (MSA) subcontractor and is the Contractor’s Key Contact who is not employed by the MSA for AHCCCS
coordination. This position is only required when the Contractor operates under a subcontract with a MSA. 

 Additional Required
Staff: 
  

	u.	Prior Authorization staff to authorize health care 24 hours per day, seven days per week. This staff shall include but is not limited to Arizona-licensed nurses, physicians and/or physician’s assistants.


  

	v.	Concurrent Review staff who are located in Arizona and who conduct inpatient concurrent review. This staff shall consist of Arizona-licensed nurses, physicians, and/or physician’s assistants.


  

	w.	Member Services staff to enable members to receive prompt resolution of their inquiries/problems. 

  

	x.	Provider Services staff who are located in Arizona and who enable providers to receive prompt responses and assistance. See Section D, Paragraph 29, Network Management. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

57 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	y.	Claims Processing staff to ensure the timely and accurate processing of original claims, resubmissions and overall adjudication of claims. 


 

	z.	Encounter Processing staff to ensure the timely and accurate processing and submission to AHCCCS of encounter data and reports. 


 

	aa.	Case Management staff who are located in Arizona and who provide care coordination for members with special health care needs. 


 

	bb.	IS Staff to ensure timely and accurate information system management to meet system and data exchange requirements. 

  

	cc.	Quality Management staff who are located in Arizona and who ensure timely, comprehensive quality of care investigative processes including but not limited to onsite quality investigations. 


The Contractor must submit the following items as specified in Attachment F3, Contractor Chart of Deliverables, and when there is a change in staffing or
organizational functions: 
  

	1.	An organization chart complete with the Key Staff positions. The chart must include the person’s name, title, location and portion of time allocated to each Medicaid contract and other lines of business.


  

	2.	A functional organization chart of the key program areas, responsibilities and reporting lines. 

  

	3.	A listing of all Key Staff to include the following: 

  

	 	a.	Individual’s name, 

  

	 	b.	Individual’s title, 

  

	 	c.	Individual’s telephone number, 

  

	 	d.	Individual’s email address, 

  

	 	e.	Individual’s location(s), 

  

	 	f.	Confirmation of applicable Key Staff functions being filled by individuals which are in good standing, and 

  

	 	g.	A list of all Key Staff functions and their locations; and a list of any functions that have moved outside of the State of Arizona in the past contract year. 


The Contractor is responsible for maintaining a significant local presence within the State of Arizona. Positions performing functions related to this
contract must have a direct reporting relationship to the local Administrator/Chief Executive Officer (CEO). The local CEO shall have the authority to direct, implement and prioritize work to ensure compliance with contract requirements. The local
CEO shall have the authority and ability to prioritize and direct work performed by Contractor staff and work performed under this contract through a management service agreement or through a delegated agreement. This significant presence includes
staff listed below. 
 In State Positions: 
  

	 	•	 	Administrator/CEO/COO 

  

	 	•	 	Behavioral Health Coordinator 

  

	 	•	 	Case Managers 

  

	 	•	 	Concurrent Review staff 

  

	 	•	 	Contract Compliance Officer 

  

	 	•	 	Corporate Compliance Officer 

  

	 	•	 	Dental Director 

  

	 	•	 	Dispute and Appeal Manager 

  

	 	•	 	Maternal Child Health/EPSDT Coordinator 

  

	 	•	 	Maternal Child Health/EPSDT staff 

  

	 	•	 	Maternal Child Health/MCH staff 

  

	 	•	 	Medical Director/CMO 

  

	 	•	 	Medical Management Manager 

  

	 	•	 	Performance/Quality Improvement Coordinator 

  

	 	•	 	Performance/Quality Improvement staff 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

58 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	 	•	 	Provider Claims Educator 

  

	 	•	 	Provider Services Manager 

  

	 	•	 	Provider Services staff 

  

	 	•	 	Quality Management Manager 

  

	 	•	 	Quality Management staff 

 Staff Training and Meeting Attendance: The Contractor shall ensure
that all staff members have appropriate training, education, experience and orientation to fulfill the requirements of the position. AHCCCS may require additional staffing for a Contractor that has substantially failed to maintain compliance with
any provision of this contract and/or AHCCCS policies. 
 The Contractor must provide initial and ongoing staff training that includes an overview of
AHCCCS; AHCCCS Policy and Procedure Manuals, and contract requirements and State and Federal requirements specific to individual job functions. The Contractor shall ensure that all staff members having contact with members or providers receive
initial and ongoing training with regard to the appropriate identification and handling of quality of care/service concerns. 
 All transportation, prior
authorization and member services representatives must be trained in the geography of any/all GSA(s) in which the Contractor holds a contract and have access to mapping search engines (e.g. MapQuest, Yahoo Maps, Google Maps) for the purposes of
authorizing services in, recommending providers in, and transporting members to, the most geographically appropriate location. 
 The Contractor shall
provide the appropriate staff representation for attendance and participation in meetings and/or events scheduled by AHCCCS. AHCCCS may require attendance by subcontracted entities, as defined in Section D, Paragraph 37, Subcontracts, when deemed
necessary. All meetings shall be considered mandatory unless otherwise indicated. 
 17. WRITTEN POLICIES AND PROCEDURES 

The Contractor shall develop and maintain written policies and procedures for each functional area consistent in format and style. The Contractor shall
maintain written guidelines for developing, reviewing and approving all policies and procedures. All policies and procedures shall be reviewed at least annually to ensure that the Contractor’s written policies reflect current practices.
Reviewed policies shall be dated and signed by the Contractor’s appropriate manager, coordinator, director or administrator. Minutes reflecting the review and approval of the policies by an appropriate committee are also acceptable
documentation. All medical and quality management policies must be approved and signed by the Contractor’s Medical Director. 
 If AHCCCS deems a
Contractor policy or process to be inefficient and/or place an unnecessary burden on the members or providers, the Contractor must work with AHCCCS to change the policy or procedure within a time period specified by AHCCCS. In addition, if AHCCCS
deems a Contractor lacks a policy or process necessary to fulfill the terms of this contract, the Contractor must work with AHCCCS to adopt a policy or procedure within a time period specified by AHCCCS. 

18. MEMBER INFORMATION 
 The Contractor shall be
accessible by phone for general member information during normal business hours. All enrolled members will have access to a toll free phone number. All informational materials, prepared by the Contractor, shall be approved by AHCCCS prior to
distribution to members. The reading level and name of the evaluation methodology used shall be included. The Contractor should refer to ACOM Policy 404 for further information and requirements. See also Attachment F3, Contractor Chart of
Deliverables. 
 All materials shall be translated when the Contractor is aware that a language is spoken by 3,000 or 10%, whichever is less, of the
Contractor’s members, who also have Limited English Proficiency (LEP). 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

59 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 All vital materials shall be translated when the Contractor is aware that a language is spoken by 1,000 or
5%, whichever is less, of the Contractor’s members, who also have LEP. Vital materials must include, at a minimum, Notices of Action, vital information from the Member Handbooks and consent forms. 

All written notices informing members of their right to interpretation and translation services in a language shall be translated when the Contractor is aware
that 1,000 or 5%, whichever is less, of the Contractor’s members speak that language and have LEP [42 CFR 438.10(c)(3)]. 
 Oral interpretation
services must be available and free of charge to all members and potential members regardless of the prevalence of the language. The Contractor must notify all members and potential members of their right to access oral interpretation services and
how to access them. Refer to ACOM Policy 404 [42 CFR 438.10(c)(4) and (5)]. 
 The Contractor shall make every effort to ensure that all information
prepared for distribution to members is written using an easily understood language and format and as further described in ACOM Policy 404 [42 CFR. 438.10(b)(1)]. Regardless of the format chosen by the Contractor, the member information must be
printed in a type, style and size, which can easily be read by members with varying degrees of visual impairment. The Contractor must notify its members that alternative formats are available and how to access them [42 CFR 438.10(d)]. The Contractor
shall adhere to the requirements for Social Networking Activities as described in ACOM Policy 425. 
 When there are program changes, notification shall be
provided to members at least 30 days before implementation. 
 Member Handbook and Provider Directory 

The Contractor shall produce and provide the following information to each member/representative or household within 12 business days of receipt of
notification of the enrollment date [42 CFR 438.10(f)(3)]: 
  

	1.	A Member Handbook which, at a minimum, shall include the items listed in ACOM Policy 404. 


The Contractor shall review and update the Member Handbook at least once a year. The Handbook must be submitted to AHCCCS, Division of Health
Care Management for approval as specified in Attachment F3, Contractor Chart of Deliverables. 
  

	2.	A Provider Directory, which at a minimum, includes those items listed in ACOM Policy 404. 


The Contractor must give written notice about termination of a contracted provider, within 15 days after receipt or issuance of the termination
notice, to each member who received their primary care from, or is seen on a regular basis by, the terminated provider [42 CFR 438.10(f)(5)]. The Contractor shall have information available for potential enrollees as described in ACOM Policy 404 [42
CFR 438.10(f)(4)]. 
 The Contractor has the option of providing the Member Handbook and Provider Directory in hard copy format with the new member packet,
or providing the member written notification of how the Member Handbook and Provider Directory information is available to the member on the Contractor’s website, via electronic mail or via postal mailing. Should the Contractor elect not to
provide the Member Handbook and Provider Directory in hard copy format with the member packet, the following provisions apply: 
  

	1.	The Contractor must submit a request for approval to forgo provision of the hard copy 60 days in advance of the member notification as specified in the Contract, Attachment F3, Contractor Chart of Deliverables.


  

	2.	The contents of the member notification must be approved in accordance with ACOM Policy 404. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

60 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	3.	The written notification must give the member the option to obtain a printed version of the Member Handbook. 

  

	4.	The information shall be available within 12 business days of receipt of notification of the enrollment date [42 CFR 438.10(f)(3)]. 


Member Newsletter 
 The Contractor must develop and
distribute, at a minimum, two member newsletters during the contract year. 
 The following types of information are to be contained in the newsletter: 

 

	1.	Educational information on chronic illnesses and ways to self-manage care 

  

	2.	Reminders of flu shots and other prevention measures at appropriate times 

  

	3.	Medicare Part D issues 

  

	4.	Cultural Competency, other than translation services 

  

	5.	Contractor specific issues (in each newsletter) 

  

	6.	Tobacco cessation information 

  

	7.	HIV/AIDS testing for pregnant women 

  

	8.	Other information as required by AHCCCS 

 Member Rights 

The Contractor will, on an annual basis, inform all members of their right to request the following information [42 CFR 438.10(f)(6) and 42 CFR 438.100(a)(1)
and (2)]. This information may be sent in a separate written communication or included with other written information such as in a member newsletter: 
  

	1.	An updated Member Handbook at no cost to the member 

  

	2.	The Provider Directory as described in ACOM Policy 404 

 The Contractor shall ensure compliance with any
applicable Federal and State laws that pertain to member rights and ensure that its staff and subcontractors take those rights into account when furnishing services to members. 

The Contractor shall ensure that each member is guaranteed the right to request and receive one copy of the member’s medical record at no cost to the
member and to request that the record be amended or corrected, as specified in 45 CFR Part 164. 
 The Contractor shall ensure that each member is free to
exercise their rights and that the exercise of those rights does not adversely affect the way the Contractor or its subcontractors treat the member [42 CFR 438.100(c)]. 

19. SURVEYS 
 The Contractor may be required to perform
surveys at AHCCCS’ request. AHCCCS may provide the survey tool or require the Contractor to develop the survey tool. The final survey tool shall be approved in advance by AHCCCS as specified in Attachment F3, Contractor Chart of Deliverables.
The results and the analysis of the results shall be submitted to the Division of Health Care Management as specified in Attachment F3, Contractor Chart of Deliverables. 

For non-AHCCCS required surveys, the Contractor shall provide notification as specified in Attachment F3, Contractor Chart of Deliverables, prior to
conducting any Contractor initiated member or provider survey. The notification must include a project scope statement, project timeline and a copy of the survey. The results and analysis of the results of any Contractor initiated surveys shall be
submitted to the Division of Health Care Management as specified in Attachment F3, Contractor Chart of Deliverables. Surveys performed by the Contractor to evaluate plan satisfaction for previous members (exit surveys), are subject to the above
notification requirement for non-AHCCCS required surveys and are not subject to Marketing Committee approval. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

61 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 AHCCCS may conduct surveys of a representative sample of the Contractor’s membership and providers. The
results of AHCCCS conducted surveys will become public information and available to all interested parties on the AHCCCS website. The Contractor will be responsible for reimbursing AHCCCS for the cost of such surveys based on its share of AHCCCS
enrollment. 
 As specified in Attachment F3, Contractor Chart of Deliverables, the Contractor is required to perform periodic surveys of its membership, as
outlined in ACOM Policy 424, in order to verify that members have received services that have been paid for by the Contractor and to identify potential service/claim fraud [42 CFR 455.20 and 433.116]. 

20. CULTURAL COMPETENCY 
 The Contractor shall ensure
compliance with a Cultural Competency Plan which meets the requirements of ACOM Policy 405. An annual assessment of the effectiveness of the plan, along with any modifications to the plan, must be submitted to the DHCM Operations Unit, as specified
in Attachment F3, Contractor Chart of Deliverables. This plan shall address cultural considerations and limited English proficiency for all services and settings [42 CFR 438.206(c)(2)]. 

21. MEDICAL RECORDS 
 The member’s medical record is
the property of the provider who generates the record. Medical records include those maintained by PCPs or other providers as well as but not limited to those kept in placement settings such as nursing facilities, assisted living facilities and
other home and community based providers. Each member is entitled to one copy of his or her medical record at no cost annually. The Contractor shall have written policies and procedures to maintain the confidentiality of all medical records.

 The Contractor is responsible for ensuring that a medical record (hard copy or electronic) is established when information is received about a member. If
the PCP has not yet seen the member such information may be kept temporarily in an appropriately labeled file, in lieu of establishing a medical record, but must be associated with the member’s medical record as soon as one is established. 

The Contractor shall have written policies and procedures for the maintenance of medical records to ensure those records are documented accurately and in a
timely manner, are readily accessible, and permit prompt and systematic retrieval of information. Medical records shall be maintained in a detailed and comprehensive manner, which conforms to professional standards, permits effective medical review
and audit processes, and which facilitates an adequate system for follow-up treatment. 
 The Contractor shall have
written standards for documentation on the medical record for legibility, accuracy and plan of care, which comply with the AMPM. 
 When a member changes
PCPs, his or her medical records or copies of medical records must be forwarded to the new PCP within 10 business days from receipt of the request for transfer of the medical records. 

AHCCCS is not required to obtain written approval from a member before requesting the member’s medical record from the PCP or any other organization or
agency. The Contractor may obtain a copy of a member’s medical records without written approval of the member if the reason for such request is directly related to the administration of the AHCCCS program. AHCCCS shall be afforded access to all
members’ medical records whether electronic or paper within 20 business days of receipt of request or more quickly if necessary. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

62 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Information related to fraud and abuse may be released, however, HIV-related information shall not be
disclosed except as provided in A.R.S. §36-664, and substance abuse information shall only be disclosed consistent with Federal and State law, including but not limited to 42 CFR 2.1 et seq. 

22. ADVANCE DIRECTIVES 
 The Contractor shall maintain
policies and procedures addressing advanced directives for adult members as specified in 42 CFR 422.128: 
  

	1.	Each contract or agreement with a hospital, nursing facility, home health agency, hospice or organization responsible for providing personal care, must comply with Federal and State law regarding advance directives for
adult members [42 CFR 438.6(i)(1)]. Requirements include: 

  

	 	a.	Maintain written policies that address the rights of adult members to make decisions about medical care, including the right to accept or refuse medical care, and the right to execute an advance directive. If the
agency/organization has a conscientious objection to carrying out an advance directive, it must be explained in policies. A health care provider is not prohibited from making such objection when made pursuant to A.R.S. §36-3205.C.1;


  

	 	b.	Provide written information to adult members regarding an individual’s rights under State law to make decisions regarding medical care, and the health care provider’s written policies concerning advance
directives, including any conscientious objections [42 CFR 438.6(i)(3)]; 

  

	 	c.	Documenting in the member’s medical record whether or not the adult member has been provided the information, and whether an advance directive has been executed; 


 

	 	d.	Not discriminating against a member because of his or her decision to execute or not execute an advance directive, and not making it a condition for the provision of care; and 


 

	 	e.	Providing education to staff on issues concerning advance directives including notification of direct care providers of services, such as home health care and personal care, if any advanced directives are executed by
members to whom they are assigned to provide services. 

  

	2.	The Contractor shall require PCPs, which have agreements with the entities described above, to comply with the requirements of subparagraphs 1 (a) through (e) above. The Contractor shall also encourage health
care providers specified in subparagraph a. to provide a copy of the member’s executed advanced directive, or documentation of refusal, to the member’s PCP for inclusion in the member’s medical record. 


 

	3.	The Contractor shall provide written information to adult members that describe the following: 

  

	 	a.	A member’s rights under State law, including a description of the applicable State law; 

  

	 	b.	The organization’s policies respecting the implementation of those rights, including a statement of any limitation regarding the implementation of advance directives as a matter of conscience; 


 

	 	c.	The member’s right to file complaints directly with AHCCCS; and 

  

	 	d.	Changes to State law as soon as possible, but no later than 90 days after the effective date of the change [42 CFR 438.6(i)(4)]. 


23. QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT 
 The
Contractor shall provide quality medical care and services to members, regardless of payer source or eligibility category. The Contractor shall promote improvement in the quality of care provided to enrolled members through established Quality
Management and Performance Improvement (QM/PI) processes. The Contractor shall execute processes to assess, plan, implement, and evaluate QM/PI activities [42 CFR 438.240]. At a minimum, the Contractor’s QM/PI programs shall comply with the
requirements outlined in the AMPM Chapters 400 and 900. See also Attachment F3, Contractor Chart of Deliverables. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

63 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 The Contractor must ensure that the QM/PI Unit within the organizational structure is separate and distinct
from any other units or departments such as Medical Management or Case Management. The Contractor is expected to integrate quality management processes, such as tracking and trending of issues, throughout all areas of the organization. Ultimate
responsibility for QM/PI activities resides within the QM/PI Unit. 
 QM/PI positions performing work functions related to the contract must have a direct
reporting relationship to the local Chief Medical Officer (CMO) and the local Chief Executive Officer (CEO). The local CMO and CEO shall have the ability to direct, implement and prioritize interventions resulting from quality management and quality
improvement activities and investigations. Contractor staff, including administrative services subcontractors’ staff, that performs functions under this contract related to QM and QI shall have the work directed and prioritized by the
Contractor’s local CEO and CMO. 
 Federal regulation prohibits payment for Provider-Preventable Conditions that meet the definition of a Health
Care-Acquired Condition (HCAC) or an Other Provider–Preventable Condition (OPPC) and that meet the following criteria:x 

 

	a.	Is identified in the State plan 

  

	b.	Has been found by the State, based upon a review of medical literature by qualified professionals, to be reasonably preventable through the application of procedures supported by evidence-based guidelines


  

	c.	Has a negative consequence for the beneficiary 

  

	d.	Is auditable 

  

	e.	Includes, at a minimum, wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the
wrong patient [42 CFR 438.6(f)(2)(i), 42 CFR 434.6(a)(12)(i), 42 CFR 447.26(b))] 

 If an
HCAC or OPPC is identified, the Contractor must report the occurrence to AHCCCS and conduct a quality of care investigation as outlined in AMPM Chapter 900 and Attachment F3, Contractor Chart of Deliverables [42 CFR 438.6(f)(2)(ii) and 42 CFR
434.6(a)(12)(ii)].xi 
 Quality Management Program 

The Contractor shall have an ongoing quality management program for the services it furnishes to members. The quality management program shall include but is
not limited to: 
  

	1.	A written QM/PI plan and an evaluation of the previous year’s QM/PI program; 

  

	2.	Quality management quarterly reports that address strategies for QM/PI activities; 

  

	3.	QM/PI program monitoring and evaluation activities which include Peer Review and Quality Management Committees which are chaired by the Contractor’s local Chief Medical Officer; 


 

	4.	Protection of medical records and any other personal health and enrollment information that identifies a particular member, or subset of members, in accordance with Federal and State privacy requirements;


  

	5.	Member rights and responsibilities [42 CFR 238.100(b)(2)(iv)]; 

  

	6.	Uniform provisional credentialing, initial credentialing, re-credentialing and organizational assessment verification [42 CFR 438.206(b)(6)]. The Contractor shall demonstrate that its providers are credentialed and
reviewed through the Contractor’s Credentialing Committee that is chaired by the Contractor’s local Medical Director [42 CFR 438.214]. The Contractor should refer to the AMPM and Attachment F3, Contractor Chart of Deliverables for
reporting requirements. The process: 

  

	 	a.	Shall follow a documented process for provisional credentialing, initial credentialing, re-credentialing and organizational credentialing verification of providers who have signed contracts or participation agreements
with the Contractor; 

  

	 	b.	Shall not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment; and 


 

	 	c.	Shall not employ or contract with providers excluded from participation in Federal health care programs. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

64 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	7.	Tracking and trending of member and provider issues, which includes, but is not limited to, investigation and analysis of quality of care issues, abuse, neglect, exploitation and unexpected deaths. The resolution
process must include: 

  

	 	a.	Acknowledgement letter to the originator of the concern; 

  

	 	b.	Documentation of all steps utilized during the investigation and resolution process; 

  

	 	c.	Follow-up with the member to assist in ensuring immediate health care needs are met; 

  

	 	d.	Closure/resolution letter that provides sufficient detail to ensure that the member has an understanding of the resolution of their issue, any responsibilities they have in ensuring all covered, medically necessary care
needs are met, and a Contractor contact name/telephone number to call for assistance or to express any unresolved concerns; 

  

	 	e.	Documentation of implemented corrective action plan(s) or action(s) taken to resolve the concern; and 

  

	 	f.	Analysis of the effectiveness of the interventions taken. 

  

	8.	Mechanisms to assess the quality and appropriateness of care furnished to members with special health care needs; 

  

	9.	Participation in community initiatives including applicable activities of the Medicare Quality Improvement Organization (QIO); and 

  

	10.	Performance improvement programs including performance measures and performance improvement projects. 


Credential Verification Organization Contract: The Arizona Association of Health Plans (AzAHP) has established a contract with a Credential
Verification Organization (CVO) that is responsible for receiving completed applications, attestations and primary source verification documents. The CVO is also responsible for conducting annual entity site visits to ensure compliance with AHCCCS
requirements. The AHCCCS Contractor must utilize the contracted CVO as part of its credentialing and recredentialing process regardless of membership in the AzAHP. This requirement eases the administrative burden for providers that contract with
AHCCCS Contractors which often results in duplicative submission of information used for credentialing purposes. The Contractor shall follow the AHCCCS recredentialing timelines for providers that submit their credentialing data and forms to the
AzAHP CVO. The Contractor is responsible for completing the credentialing process. The Contractor shall continue to include utilization, performance, complaint, and quality of care information, as specified in the AMPM, to complete the credentialing
or recredentialing files that are brought to the Credentialing Committee for a decision. In addition, the Contractor must also meet the AMPM requirements for provisional/temporary credentialing. 

Credentialing Timelines: The Contractor is required to process credentialing applications in a timely manner. To assess the timeliness of
provisional and initial credentialing a Contractor shall calculate and report to AHCCCS as outlined in AMPM Policy 950. The Contractor must report the credentialing information with regard to all credentialing applications as specified in
Attachment F3, Contractor Chart of Deliverables. 
 Quality Improvement: The Contractor’s quality management program shall be designed to
achieve and sustain, through ongoing measurements and intervention, significant improvement in the areas of clinical care and nonclinical care which are expected to have a favorable effect on health outcomes and member satisfaction. The Contractor
must [42 CFR 438.240(b)(2) and (c)]: 
  

	1.	Measure and report to the State its performance, using standard measures required by the AHCCCS, or as required by CMS; 

  

	2.	Submit specified data to the State that enables the State to measure the Contractor’s performance; or 

  

	3.	Perform a combination of the above activities. 

 The Contractor shall have an ongoing program of performance
improvement projects that focus on clinical and non-clinical areas, as specified in the AMPM, and that involve the following [42 CFR 438.240(b)(1) and (d)(1)]: 
  

	1.	Measurement of performance using objective quality indicators 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

65 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	2.	Implementation of system interventions to achieve improvement in quality 

  

	3.	Evaluation of the effectiveness of the interventions 

  

	4.	Planning and initiation of activities for increasing or sustaining improvement 

 Performance Measures

 The Contractor shall comply with AHCCCS quality management requirements to improve performance for all AHCCCS performance measures. Descriptions of
the AHCCCS Clinical Quality Performance Measures and links to the CMS and the measure host sites can be found on the AHCCCS website. The EPSDT Participation performance measure description utilizes the methodology established in CMS “Form
416” which can also be found on the AHCCCS website at: 
 http://www.azahcccs.gov/reporting/quality/performancemeasures.aspx. 

The Contractor must comply with Federal performance measures and levels that may be identified and developed by CMS or those developed in consultation with
AHCCCS and/or other relevant stakeholders. CMS has been working in partnership with states in developing core performance measures for Medicaid and CHIP programs. As the Core Measure sets are implemented, performance measures required by AHCCCS may
be updated to include these measures. 
 AHCCCS may utilize a hybrid or other methodologies for collecting and reporting performance measure rates, as
allowed by the National Committee of Quality Assurance NCQA, for selected Healthcare Effectiveness Data and Information Set (HEDIS) measures or as allowed by other entities for nationally recognized measure sets. The Contractor shall collect data
from medical records, electronic records or through approved processes such as those utilizing a health information exchange and provide these data with supporting documentation, as instructed by AHCCCS, for each hybrid measure. The number of
records that each Contractor collects will be based on HEDIS, External Quality Review Organization (EQRO), or other sampling guidelines and may be affected by the Contractor’s previous performance rate for the measure being collected. 

The Contractor must have a process in place for monitoring performance measure rates. The Contractor shall utilize a standard methodology established or
adopted by AHCCCS for measurement of each required performance measure. The Contractor’s QM/PI Program will report its measured performance on an ongoing basis to its Administration. The Contractor performance measure monitoring results shall
also be reported to AHCCCS in conjunction with its EPSDT Improvement and Adult Quarterly Monitoring Report. 
 The Contractor must meet AHCCCS stated
Minimum Performance Standards (MPS) for each population/eligibility category for which AHCCCS reports results. AHCCCS-reported rates are the official rates utilized for determination of Contractor compliance with performance requirements. It is
equally important that, in addition to meeting the contractual MPS, the Contractor continually improve performance measure outcomes from year to year. Contractor calculated and/or reported rates will be used strictly for monitoring Contractor
actions and not be used for official reporting or for consideration in corrective action purposes. 
 Minimum Performance Standard
– MPS is the minimal expected level of performance by the Contractor. If a Contractor does not achieve this standard, the Contractor will be required to submit a corrective action plan and may be subject to a sanction of up to $100,000 dollars
for each deficient measure. 
 A Contractor must show demonstrable and sustained improvement toward meeting AHCCCS Performance Standards. AHCCCS may impose
sanctions on Contractors that do not show statistically significant improvement in a measure rate as calculated by AHCCCS. Sanctions may also be imposed for statistically significant declines of rates even if they meet or exceed the MPS, for any
rate that does not meet the AHCCCS MPS, or a rate that has a significant impact to the aggregate rate for the State. AHCCCS may require the Contractor to demonstrate that they are allocating increased administrative resources to improving rates for
a particular measure or service area. AHCCCS also may require a corrective action plan for measures that are below the MPS or that show a statistically significant decrease in its rate even if it meets or exceeds the MPS. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

66 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 An evidence-based corrective action plan that outlines the problem, planned actions for improvement,
responsible staff and associated timelines as well as a place holder for evaluation of activities must be received by AHCCCS within 30 days of receipt of notification of the deficiency from AHCCCS. This plan must be approved by AHCCCS prior to
implementation. AHCCCS may conduct one or more follow-up desktop or on-site reviews to verify compliance with a corrective action plan. 
 All Performance
Measures apply to all member populations [42 CFR 438.240(a)(2), (b)(2) and (c)]. AHCCCS may analyze and report results by line of business, Geographical Service Area (GSA), or County, and/or other applicable demographic factors. 

AHCCCS has established standards for the measures listed below. 

The following table identifies the MPS for each measure: 
  

					
	 Acute Care Performance Measures
	 
	 Performance Measure
	  	Minimum Performance Standard (MPS)	 
	 ADULT MEASURES
	 
	 Inpatient Utilization*
	  	 	TBD	  
	 Ambulatory Care - Emergency Department (ED) Visits*
	  	 	TBD	  
	 Readmissions within 30 days of discharge*
	  	 	TBD	  
	 Adult asthma Admission Rate*
	  	 	TBD	  
	 Use of Appropriate Medications for People with Asthma
	  	 	86	% 
	 Follow-up After Hospitalization (all cause) within 7 Days
	  	 	50	% 
	 Follow-up After Hospitalization (all cause) within 30 Days
	  	 	70	% 
	 Adults’ Access to Preventive/Ambulatory Health Services
	  	 	75	% 
	 Breast Cancer Screening
	  	 	50	% 
	 Cervical Cancer Screening: Women Aged 21-64 with a Cervical Cytology Performed Every Three (3) Years
	  	 	64	% 
	 Cervical Cancer Screening: Women Aged 30-64 with a Cervical Cytology/Human Papillomavirus (HPV) Co-Testing Performed Every Five (5)
Years
	  	 	64	% 
	 Chlamydia Screening in Women Aged 16 to 24
	  	 	63	% 
	 Comprehensive Diabetes Management
	  			
	 HbA1c Testing
	  	 	77	% 
	 HbA1c Poor Control (>9.0%)
	  	 	TBD	  
	 LDL-C Screening
	  	 	70	% 
	 Eye Exam
	  	 	49	% 
	 Flu Shots for Adults, Ages 18+
	  	 	50	% 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

67 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


					
	 Diabetes Admissions, short-term complications*
	  	 	TBD	  
	 Chronic Obstructive Pulmonary Disease (COPD)/Asthma in Older Adults Admissions*
	  	 	TBD	  
	 Asthma in Younger Adults Admissions*
	  	 	TBD	  
	 Congestive Heart Failure admissions*
	  	 	TBD	  
	 Annual monitoring for patients on persistent medications: Combo Rate
	  	 	75	% 
	 Timeliness of Prenatal Care: Prenatal Care visit in the first trimester or within 42 days of enrollment
	  	 	80	% 
	 Prenatal and Postpartum Care: Postpartum Care Rate (second component to CHIPRA core measure “Timeliness of Prenatal
Care)*
	  	 	64	% 
	 CHILDRENS MEASURES
	   

	 Children’s Access to PCPs, by age: 12-24 mo.
	  	 	93	% 
	 Children’s Access to PCPs, by age: 25 mo.- 6 yrs.
	  	 	84	% 
	 Children’s Access to PCPs, by age: 7 - 11 yrs.
	  	 	83	% 
	 Children’s Access to PCPs, by age: 12 - 19 yrs.
	  	 	82	% 
	 Well-Child Visits: 15 mo.
	  	 	65	% 
	 Well-Child Visits: 3 - 6 yrs.
	  	 	66	% 
	 Adolescent Well-Child Visits: 12–21 yrs.
	  	 	41	% 
	 Children’s Dental Visits: (ages 2-21)
	  	 	60	% 
	 Weight Assessment and Counseling...Body Mass Index (BMI) Assessment for Children/Adolescents
	  	 	50	% 
	 EPSDT Participation (2)
	  	 	68	% 
	 Percentage of Eligibles Who Received Preventive Dental Services (previously titled EPSDT Dental Participation) (3)
	  	 	46	% 
	 Ambulatory Care - Emergency Department (ED) Visits*
	  	 	TBD	  
	 Inpatient Utilization*
	  	 	TBD	  
	 Hospital Readmission Rate*
	  	 	TBD	  
	 Developmental Screening in the First Three Years of Life
	  	 	55	% 
	 Childhood Immunization Status
	   

	 DTaP
	  	 	85	% 
	 IPV (1)
	  	 	91	% 
	 MMR (1)
	  	 	91	% 
	 Hib (1)
	  	 	90	% 
	 HBV (1)
	  	 	90	% 
	 VZV (1)
	  	 	88	% 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

68 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


					
	 PCV (1)
	  	 	82	% 
	 4:3:1:3:3:1 Series
	  	 	74	% 
	 4:3:1:3:3:1:4 Series
	  	 	68	% 
	 Hepatitis A (HAV)
	  	 	40	% 
	 Rotovirus
	  	 	60	% 
	 Influenza
	  	 	45	% 
	 Immunizations for Adolescents
	   

	 Adolescent Meningococcal
	  	 	75	% 
	 Adolescent Tdap
	  	 	75	% 
	 Adolescent Combo
	  	 	75	% 
	 Human Papillomavirus Vaccine for Female Adolescents
	  	 	50	% 

 Notes: 
  

	(*)	AHCCCS will develop Minimum Performance Standards and Goals once baseline data has been analyzed for these measures. 


	(1) 	AHCCCS will continue to measure and report results of these individual antigens; however, a Contractor may not be held accountable for specific Performance Standards unless AHCCCS determines that completion of a
specific antigen or antigens is affecting overall completion of the childhood immunization series. 


	(2) 	The EPSDT Participation rate is the percent of all children and adolescents younger than 21 years who were due for at least one EPSDT visit, depending on their age and the state’s EPSDT Periodicity Schedule, and
had a visit during the contract year. 


	(3) 	Preventive Dental Standards are based on the CMS-established goal that States improve their rate of children ages one through 20 enrolled in Medicaid and who received any preventive dental service, by 10 percentage
points over a five-year period. 

 Contractor Performance is evaluated annually using the AHCCCS-reported rate for each measure. AHCCCS rates
are considered the official measurement for each Performance Measure. AHCCCS calculated rates by Contractor for each measure will be compared with the MPS specified in the contract in effective during the measurement period. For instance,
Performance Standards in the CYE 2015 contract apply to results calculated by AHCCCS for the CYE 2015 measurement period. AHCCCS will utilize methodologies that are reflective of the requirements for the measurement period. For instance, CYE 2014
performance measure data will be based on the published 2014 CMS Core Sets and 2014 HEDIS technical specifications. Contractors are responsible for monitoring and reporting to AHCCCS CQM the status of, and any discrepancies identified in encounters
received by AHCCCS including paid, denied and pended for purposes of Performance Measure monitoring prior to the AHCCCS Performance Measure rate calculations being conducted. 

The Contractor shall participate in immunization audits, at intervals specified by AHCCCS, based on random sampling to verify the immunization status of
members at 24 months of age and by 13 years of age. If records are missing for more than five percent (5%) of the Contractor’s final sample, the Contractor is subject to sanctions by AHCCCS. An External Quality Review Organization (EQRO)
may conduct a study to validate the Contractor’s reported rates. 
 AHCCCS will measure and report the Contractor’s EPSDT Participation rate and
Dental Participation (Preventive Dental) rate, utilizing the CMS 416 methodology. The EPSDT participation rate is the number of children younger than 21 years that receive medical screens in compliance with the State’s Periodicity


  
 Acute Care Contract 

10/01/2015 Renewal 
  

69 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 
Schedule, compared to the number of children expected to receive medical screens per the State’s Periodicity Schedule. The Preventive Dental Participation rate is the number of children aged
one through 20 who have a preventive dental visit, compared to the number of children who has at least 90-days continuous enrollment during the Contract Year (measurement period). 

The Contractor is responsible for applying the correct CMS-416 methodology as developed and maintained by CMS for its internal monitoring of performance
measure results. 
 AHCCCS uses the national CMS 416 methodology to generate the EPSDT Participation and Dental Participation rates through a CMS-validated
process. The rates are generated one time a year and reported to CMS within specified timeframes. Aggregate rates as well as Contractor-specific rates are included in this process. 

The Contractor must participate in the delivery and/or results review of member surveys as requested by AHCCCS. Surveys may include Home and Community Based
(HCBS) Member Experience surveys, HEDIS Experience of Care (Consumer Assessment of Healthcare Providers and Systems – CAHPS) surveys, and/or any other tool that AHCCCS determines will benefit quality improvement efforts. While not included as
an official performance measure, survey findings or performance rates for survey questions may result in the Contractor being required to develop a Corrective Action Plan (CAP) and/or participate in technical assistance or AHCCCS-led workgroups to
improve any areas of concern noted by AHCCCS. Failure to effectively develop or implement AHCCCS-approved CAPs and drive improvement may result in additional regulatory action. 

The Contractor must monitor rates for postpartum visits and low/very low birth weight deliveries and implement interventions as necessary to improve or
sustain these rates. The Contractor must implement processes to monitor and evaluate cesarean section and elective inductions rates prior to 39 weeks gestation to ensure medical necessity, and implement interventions to decrease the incidence of
occurrence. 
 Performance Improvement Projects (PIPs): The Contractor shall have an ongoing program of performance improvement projects that
focus on clinical and non-clinical areas as specified in the AMPM, and that involve the following: [42 CFR 438.240(b)(1) and (d)(1)] 
  

	a.	Measurement of performance using objective quality indicators; 

  

	b.	Implementation of system interventions to achieve improvement in quality; 

  

	c.	Evaluation of the effectiveness of the interventions; 

  

	d.	Planning and initiation of activities for increasing or sustaining improvement. 

 PIPs are mandated by AHCCCS,
the Contractor should also self-select additional projects based on opportunities for improvement identified by internal data and information. The Contractor shall report the status and results of each project to AHCCCS as requested using the AHCCCS
PIP Reporting Template included in the AMPM. Each PIP must be completed in a reasonable time period to allow information on the success of PIPs in the aggregate to produce new information on quality of care every year [42 CFR 438.240(d)(2)]. 

Data Collection Procedures: When requested by AHCCCS, the Contractor must submit data for standardized Performance Measures and/or PIPs within
specified timelines and according to AHCCCS procedures for collecting and reporting the data. The Contractor is responsible for collecting valid and reliable data and using qualified staff and personnel to collect the data. The Contractor must
ensure that data collected by multiple parties/people for Performance Measures and/or PIP reporting is comparable and that an inter-rater reliability process was used to ensure consistent data collection. Data collected for Performance Measures
and/or PIPs must be returned by the Contractor in a format specified by AHCCCS, and by the due date specified. Any extension for additional time to collect and report data must be made in writing in advance of the initial due date and is subject to
approval by AHCCCS. Failure to follow the data collection and reporting instructions that accompany the data request may result in sanctions imposed on the Contractor. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

70 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 24. MEDICAL MANAGEMENT 

The Contractor shall implement processes to assess, plan, implement, evaluate, and as mandated, report Medical Management (MM) monitoring activities as
specified in the AMPM Chapter 1000. This shall include the Quarterly Inpatient Hospital Showings report, HIV Specialty Provider List, Transplant Report and Prior Authorization Requirements report as specified in the AMPM and Attachment F3,
Contractor Chart of Deliverables. The Contractor shall evaluate MM activities, as specified in the AMPM Chapter 1000, including: 
  

	1.	Pharmacy Management; including the evaluation, reporting, analysis and interventions based on the data and reported through the MM Committee, which is chaired by the Contractor’s Chief Medical Officer.


  

	2.	Prior authorization and Referral Management; for the processing of requests for initial and continuing authorizations of services the Contractor shall: 


 

	 	a.	Have in effect mechanisms to ensure consistent application of review criteria for authorization decisions; 

  

	 	b.	Consult with the requesting provider when appropriate [42 CFR 438.210(b)(2)]; 

  

	 	c.	Monitor and ensure that all enrollees with special health care needs have direct access to care; 

  

	 	d.	Review all prior authorization requirements for services, items or medications annually. The review will be reported through the MM Committee and will include the rationale for changes made to prior authorization
requirements. A summary of the prior authorization requirement changes and the rationale for those changes must be included in the annual MM Evaluation submission; and 


 

	 	e.	Comply with all decision timelines as outlined in the ACOM and the AMPM. 

  

	3.	Development and/or Adoption of Practice Guidelines [42 CFR 438.236(b)] that: 

  

	 	a.	Are based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field; 

  

	 	b.	Consider the needs of the Contractor’s members; 

  

	 	c.	Are adopted in consultation with contracting health care professionals; 

  

	 	d.	Are reviewed and updated periodically as appropriate; 

  

	 	e.	Are disseminated by the Contractor to all affected providers and, upon request, to enrollees and potential enrollees [42 CFR 438.236(c)]; and 


 

	 	f.	Provide a basis for consistent decisions for utilization management, member education, coverage of services, and other areas to which the guidelines apply [42 CFR 438.236(d)]. 


 

	4.	Concurrent review: 

  

	 	a.	Consistent application of review criteria; provide a basis for consistent decisions for utilization management, coverage of services, and other areas to which the guidelines apply; 


 

	 	b.	Contractors must have policies and procedures in place that govern the process for proactive discharge planning when members have been admitted into acute care facilities. The intent of the discharge planning policy and
procedure would be to increase the utilization management of inpatient admissions and decrease readmissions within 30 days of discharge; and 

  

	 	c.	In addition, 42 CFR 447.26 prohibits payment for Provider-Preventable Conditions that meet the definition of a Health Care-Acquired Condition (HCAC) or an Other Provider–Preventable Condition (OPPC) (refer to AMPM
Chapter 1000). If an HCAC or OPPC is identified, the Contractor must report the occurrence to AHCCCS and conduct a quality of care investigation. 

  

	5.	Continuity and coordination of care: 

  

	 	a.	Establish a process to ensure coordination of member care needs across the continuum based on early identification of health risk factors or special care needs; 


 

	 	b.	Establish a process for timely and confidential communication of clinical information among providers; 

  

	 	c.	Must proactively provide care coordination for members who have multiple complaints regarding services or the AHCCCS Program. This includes, but is not limited to, members who do not meet the Contractor’s criteria
for case management; and 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

71 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	 	d.	Must proactively provide care coordination for members who have both behavioral health and physical health needs. The Contractor must meet regularly with the Regional Behavioral Health Authorities to improve and address
coordination of care issues. Meetings shall occur at least every other month or more frequently if needed to develop processes, implement interventions, and discuss outcomes. Care coordination meetings and staffings shall occur at least monthly or
more often as necessary to affect change. 

 The Contractor shall implement and report the following: 

 

	 	•	 	Identify High Need/High Cost members for each Regional Behavioral Health Authority (RBHA) Geographic Service Area as specified in Section B, Capitation Rates and Contractor Specific Requirements in accordance with the
standardized criteria developed by the AHCCCS/Contractor workgroup; 

  

	 	•	 	Members included in the High Need/High Cost Program prior to October 1, 2015 from relinquishing RBHAs must be included in the ongoing High Need/High Cost Program. 


 

	 	•	 	Plan interventions for addressing appropriate and timely care for these identified members; and 

  

	 	•	 	Report outcome summaries to AHCCCS and DBHS utilizing the standardized template developed by the AHCCCS/Contractor workgroup as specified in Attachment F3, Contractor Chart of Deliverables. 


 

	6.	Monitor and evaluate over and/or underutilization of services [42 CFR 438-240(b)(3)]; 

  

	7.	Evaluate new medical technologies, and new uses of existing technologies; and 

  

	8.	Disease Management or Chronic Care Program that reports results and provides for analysis of the program through the MM Committee. 


AHCCCS will provide a new Contractor (including an Incumbent Contractor new to a GSA) with three years of historical Acute Care Program encounter data for
members enrolled with the Contractor as of December 1, 2013. Contractors should use this data to assist with identifying members in need of medical management. 

On a recurring basis (no less than quarterly based on adjudication date), AHCCCS shall provide the Contractor an electronic file of claims and encounter data
for members enrolled with the Contractor who have received services, during the member’s enrollment period, from another contractor or through AHCCCS FFS for purposes of member care coordination. 

The Contractor shall develop a plan outlining short- and long-term strategies for improving care coordination using the physical and behavioral health care
data available for members with behavioral health needs. In addition, the Contractor shall develop an outcome measurement plan to track the progress of the strategies. The plan outlining the strategies for improving care coordination and the outcome
measurement must be reported in the annual MM Plan, Evaluation and Work Plan submitted to AHCCCS as specified in Attachment F3, Contractor Chart of Deliverables. 

The Contractor shall have a process to report MM data and management activities through a MM Committee. The Contractor’s MM Committee will analyze the
data, make recommendations for action, monitor the effectiveness of actions and report these findings to the Committee. The Contractor shall have in effect mechanisms to assess the quality and appropriateness of care furnished to members with
special health care needs [42 CFR 438.240(b)(4)]. 
 The Contractor will assess, monitor and report quarterly through the MM Committee medical decisions to
assure compliance with timeliness, language, Notice of Action intent, and that the decisions comply with all Contractor coverage criteria. This includes quarterly evaluation of all Notice of Action decisions that are made by a subcontracted entity.

 The Contractor shall maintain a written MM plan and Work Plan that addresses the monitoring of MM activities (AMPM Chapter 1000). The Plan and Work Plan
must be submitted for review within timelines specified in Attachment F3, Contractor Chart of Deliverables. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

72 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 The Contractor is required to report to AHCCCS, as specified in Attachment F3, Contractor Chart of
Deliverables, a restriction report which includes the number of members which on the date of the report are restricted to using a specific Pharmacy or Prescriber/Providers due to excessive use of prescriptive medications (narcotics and
non-narcotics). 
 The Contractor is required to report to AHCCCS, as specified in Attachment F3, Contractor Chart of Deliverables, a monthly Hepatitis C
Virus (HCV) Medication Report. Data is reported for all HCV medication activity for the month being reported. The total number of requests received, approvals, denials, and appeals for any given month are to be included in the report. As
outcome information becomes available, it is to also be included in the report for the month received. The Contractor will be reporting as a January activity (due February 10th)
any information received regarding outcomes, appeals, hearings, and so forth for medication approvals from past months.
 AHCCCS covers medically necessary
transplantation services and related immunosuppressant medications in accordance with Federal and State law and regulations. The Contractor shall not make payments for organ transplants not provided for in the State Plan except as otherwise required
pursuant to 42 USC 1396 (d)(r)(5) for persons receiving services under EPSDT. The Contractor must follow the written standards that provide for similarly situated individuals to be treated alike and for any restriction on facilities or practitioners
to be consistent with the accessibility of high quality care to enrollees per Sections (1903(i) and 1903(i)(1)) of the Social Security Act. Refer to the AMPM, Chapter 300, Exhibit 310-DD and the AHCCCS Reinsurance Policy Manual.xii 
 25. TELEPHONE PERFORMANCE STANDARDS 

The Contractor must meet and maintain established telephone performance standards to ensure member and provider satisfaction as specified in ACOM Policy 435.
The Contractor shall report on compliance with these standards as specified in Attachment F3, Contractor Chart of Deliverables and the policy identified above. All reported data is subject to validation through periodic audits and/or operational
reviews. 
 26. GRIEVANCE SYSTEM 
 The Contractor shall
have in place a written grievance system process for subcontractors, enrollees and non-contracted providers, which define their rights regarding disputed matters with the Contractor. The Contractor’s grievance system for enrollees includes a
grievance process (the procedures for addressing enrollee grievances), an appeals process and access to the State’s fair hearing process as outlined in Attachment F1, Enrollee Grievance System Standards. The Contractor’s dispute process
for subcontractors and non-contracted providers includes a claim dispute process and access to the State’s fair hearing process as outlined in Attachment F2, Provider Claim Dispute Standards. The Contractor shall remain responsible for
compliance with all requirements set forth in Attachments F1, Enrollee Grievance System Standards, F2, Provider Claim Dispute Standards, and 42 CFR Part 438 Subpart F. 

Information to enrollees must meet cultural competency and limited English proficiency requirements as specified in Section D, Paragraph 18, Member
Information and Paragraph 20, Cultural Competency. 
 The Contractor shall provide the appropriate professional, paraprofessional and clerical personnel for
the representation of the Contractor in all issues relating to the grievance system and any other matters arising under this contract which rise to the level of administrative hearing or a judicial proceeding. Unless there is an agreement with the
State in advance, the Contractor shall be responsible for all attorney fees and costs awarded to the claimant in a judicial proceeding. 
 The Contractor
may delegate the grievance system process to subcontractors, however, the Contractor must ensure that the delegated entity complies with applicable Federal and State laws, regulations and policies, including, but not limited to 42 CFR Part 438
Subpart F. The Contractor shall remain responsible for 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

73 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 
compliance with all requirements. The Contractor shall also ensure that it timely provides written information to both enrollees and providers, which clearly explains the grievance system
requirements. This information must include a description of: the right to a State fair hearing, the method for obtaining a State fair hearing, the rules that govern representation at the hearing, the right to file grievances, appeals and claim
disputes, the requirements and timeframes for filing grievances, appeals and claim disputes, the availability of assistance in the filing process, the toll-free numbers that the enrollee can use to file a grievance or appeal by phone, that benefits
will continue when requested by the enrollee in an appeal or State fair hearing request concerning certain actions which are timely filed, that the enrollee may be required to pay the cost of services furnished during the appeal/hearing process if
the final decision is adverse to the enrollee, and that a provider may file an appeal on behalf of an enrollee with the enrollee’s written consent. 

The Contractor must provide reports on the Grievance System as required in the AHCCCS Grievance System Reporting Guide available on the AHCCCS website. See
also Attachment F3, Contractor Chart of Deliverables. 
 27. NETWORK DEVELOPMENT 

The Contractor shall develop and maintain a provider network that is supported by written agreements which is sufficient to provide all covered services to
AHCCCS members, including covered behavioral health services for adult dual members receiving general mental health and substance abuse services. The Contractor shall ensure covered services are reasonably accessible in terms of location and hours
of operation. The Contractor must provide a comprehensive provider network that ensures its membership has access at least equal to community norms. Services shall be as accessible to AHCCCS members in terms of timeliness, amount, duration and scope
as those services are available to non-AHCCCS persons within the same service area [42 CFR 438.210(a)(2)]. The Contractor is encouraged to have available non-emergent after-hours physician or primary care services within its network. If the
Contractor’s network is unable to provide medically necessary services required under contract, the Contractor must adequately and timely cover these services through an out of network provider until a network provider is contracted. The
Contractor shall ensure coordination with respect to authorization and payment issues in these circumstances [42 CFR 438.206(b)(4) and (5)]. The Contractor is expected to develop a provider network that supports the provision of covered behavioral
health services for adult dual members receiving general mental health and substance abuse services. The Contractor may not subcontract for or delegate to another entity for the delivery of behavioral health services. 

The Contractor is expected to design a network that provides a geographically convenient flow of patients among network providers to maximize member choice.
The provider network shall be designed to reflect the needs and service requirements of AHCCCS’ culturally and linguistically diverse member population. The Contractor shall design its provider networks to maximize the availability of community
based primary care and specialty care access and that reduces utilization of emergency services, one day hospital admissions, hospital based outpatient surgeries when lower cost surgery centers are available, and hospitalization for preventable
medical problems. 
 There shall be sufficient personnel for the provision of covered services, including emergency medical care on a 24-hour-a-day,
seven-days-a-week basis [42 CFR 438.206(c)(1)(iii)]. 
 The Contractor shall develop and maintain a Provider Network Development and Management Plan which
ensures that the provision of covered services will occur as stated above [42 CFR 438.207(b)]. The requirements for the Network Development and Management Plan are found in ACOM Policy 415. The Network Development and Management Plan shall be
evaluated, updated annually and submitted to AHCCCS as specified in Attachment F3, Contractor Chart of Deliverables. The submission of the network management and development plan to AHCCCS is an assurance of the adequacy and sufficiency of the
Contractor’s provider network. The Contractor shall also submit, as needed, an assurance when there has been a significant change in operations that would affect adequate capacity and services. These changes would include, but would not be
limited to, changes in services, covered benefits, geographic service areas, payments or eligibility of a new population. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

74 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 In accordance with the requirements specified in ACOM Policy 436 the network shall be sufficient to provide
covered services within designated time and distance limits. This includes a network such that 90% of its members residing within Pima and Maricopa counties do not have to travel more than 15 minutes or 10 miles to visit a PCP, dentist or pharmacy,
unless accessing those services through a Multi-Specialty Interdisciplinary Clinic (MSIC). The Contractor must obtain hospital contracts as specified in ACOM Policy 436. 

The Contractor shall not discriminate with respect to participation in the AHCCCS program, reimbursement or indemnification against any provider based solely
on the provider’s type of licensure or certification [42 CFR 438.12(a)(1)(2)]. In addition, the Contractor must not discriminate against particular providers that service high-risk populations or specialize in conditions that require costly
treatment [42 CFR 438.214(c)]. This provision, however, does not prohibit the Contractor from limiting provider participation to the extent necessary to meet the needs of the Contractor’s members. This provision also does not interfere with
measures established by the Contractor to control costs and quality consistent with its responsibilities under this contract nor does it preclude the Contractor from using different reimbursement amounts for different specialists or for different
practitioners in the same specialty [42 CFR 438.12(b)(1)]. If a Contractor declines to include individuals or groups of providers in its network, it must give the affected providers timely written notice of the reason for its decision [42 CFR
438.12(a)(1)]. The Contractor may not include providers excluded from participation in Federal health care programs, under either section 1128 or section 1128A of the Social Security Act [42 CFR 438.214(d)]. 

MSICs are established facilities providing interdisciplinary services for members with qualifying CRS conditions and are under contract with the CRS
Contractor. Contractors are encouraged to contract with MSICs for specialty care. Pediatric specialists that work in the MSIC are in limited quantity in Arizona. Contracting with the MSICs provides Contractors an opportunity to increase access to
these pediatric specialists. 
 The Contractor must pay all AHCCCS registered Arizona Early Intervention Program (AzEIP) providers, regardless of their
contract status with the Contractor, when Individual Family Service Plans identify and meet the requirement for medically necessary EPSDT covered services. 

The Contractor is also encouraged to develop non-financial incentive programs to increase participation in its provider network. 

AHCCCS is committed to workforce development and support of the medical residency and dental student training programs in the State of Arizona. AHCCCS expects
the Contractor to support these efforts. AHCCCS encourages plans to contract with or otherwise support the many Graduate Medical Education (GME) Residency Training Programs currently operating in the State and to investigate opportunities for
resident participation in Contractor medical management and committee activities. In the event of a contract termination between the Contractor and a GME Residency Training Program or training site, the Contractor may not remove members from that
program in such a manner so as to harm the stability of the program. AHCCCS reserves the right to determine what constitutes risk to the program. Further, the Contractor must attempt to contract with graduating residents and providers that are
opening new practices in, or relocating to, Arizona, especially in rural or underserved areas. 
 Homeless Clinics: Contractors in Maricopa
and Pima County must contract with homeless clinics at the AHCCCS Fee-For-Service rate for Primary Care services. Contracts must stipulate that: 
 1. Only
those members who request a homeless clinic as a PCP may be assigned to them; and 
 2. Members assigned to a homeless clinic may be referred out-of-network
for needed specialty services. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

75 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 The Contractor must make resources available to assist homeless clinics with administrative issues such as
obtaining prior authorization, and resolving claims issues. 
 28. PROVIDER AFFILIATION TRANSMISSION 

The Contractor must submit information quarterly regarding its provider network. This information must be submitted in the format described in the Provider
Affiliation Transmission (PAT) User Manual which can be found on the AHCCCS website. The Contractor shall also validate its compliance with minimum network requirements against the network information provided in the PAT through the submission of a
completed Minimum Network Requirements Verification Template (see ACOM Policy 436 for Template). The PAT and the Minimum Network Requirements Verification Template must be submitted as specified in Attachment F3, Contractor Chart of Deliverables.

 29. NETWORK MANAGEMENT 
 The Contractor shall have
policies on how the Contractor will [AMPM, 42 CFR 438.214(a)]: 
  

	a.	Communicate with the network regarding contractual and/or program changes and requirements; 

  

	b.	Monitor network compliance with policies and rules of AHCCCS and the Contractor, including compliance with all policies and procedures related to the grievance/appeal processes and ensuring the member’s care is not
compromised during the grievance/appeal processes; 

  

	c.	Evaluate the quality of services delivered by the network; 

  

	d.	Provide or arrange for medically necessary covered services should the network become temporarily insufficient within the contracted service area; 


 

	e.	Monitor the adequacy, accessibility and availability of its provider network to meet the needs of its members, including the provision of care to members with limited proficiency in English; 


 

	f.	Process provisional credentials; 

  

	g.	Recruit, select, credential, re-credential and contract with providers in a manner that incorporates quality management, utilization, office audits and provider profiling; 


 

	h.	Provide training for its providers and maintain records of such training; 

  

	i.	Track and trend provider inquiries/complaints/requests for information and take systemic action as necessary and appropriate; and 

  

	j.	Ensure that provider calls are acknowledged within three business days of receipt, resolved and/or state the result communicated to the provider within 30 business days of receipt (this includes referrals from AHCCCS).


 Contractor policies shall be subject to approval by AHCCCS, Division of Health Care Management, and shall be monitored through operational
audits. 
 The Contractor shall hold a Provider Forum no less than semi-annually. The forum must be chaired by the Contractor’s Administrator/CEO or
designee. The purpose of the forum is to improve communication between the Contractor and its providers. The forum shall be open to all providers including dental providers. The Provider Forum shall not be the only venue for the Contractor to
communicate and participate in the issues affecting the provider network. Provider Forum meeting agendas and minutes must be made available to AHCCCS upon request. The Contractor shall report information discussed during these Forums to Executive
Management within the organization. 
 Material Change to Provider Network: The Contractor is responsible for evaluating all provider network
changes, including unexpected or significant changes, and determining whether those changes are material changes to the Contractor’s provider network [42 CFR 438.207 (c)]. All material changes to the provider network must be approved in advance
by AHCCCS, Division of Health Care Management. A material change to the provider network is defined as one that affects, or can reasonably be foreseen to affect, the Contractor’s ability to meet the performance and/or provider network standards
as described in this contract including, but not limited to, any change that would cause or is likely to cause more than 5% of members in a GSA to change the location where services are received or rendered. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

76 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 The Contractor must submit the request for approval of a material change to the provider network with
information including, but not limited to, how the change will affect the delivery of covered services, the Contractor’s plans for maintaining the quality of member care, and communications to providers and members, as outlined in ACOM Policy
439 and as specified in Attachment F3, Contractor Chart of Deliverables. AHCCCS will review and respond to the Contractor within 30 days of the submission. A material change in the Contractor’s provider network requires 30 days advance written
notice from the Contractor to members and providers. In the event unforeseen circumstances prevent the Contractor from providing 30 days advance written notice to members and providers, the Contractor shall notify AHCCCS within one business day of
identifying the material change to the provider network for AHCCCS determination of notification requirements. 
 For emergency situations, AHCCCS will
expedite the approval process. 
 The requirements regarding material changes to the provider network do not apply to the contract negotiation process
between the Contractor and a provider. 
 See Section D, Paragraph 44, regarding material changes by the Contractor that may impact business operations.

 See Section D, Paragraph 55, Capitation Adjustments regarding material changes by the Contractor that may impact capitation rates. 

The Contractor shall give hospitals and provider groups 90 days’ notice prior to a contract termination without cause. Contracts between the Contractor
and single practitioners are exempt from this requirement. 
 Provider/Network Changes Report: The Contractor must submit a Quarterly
Provider/Network Changes Due to Rates Report as described in ACOM Policy 415 and Attachment F3, Contractor Chart of Deliverables. 
 30. PRIMARY CARE
PROVIDER STANDARDS 
 The Contractor shall include in its provider network a sufficient number of Primary Care Providers (PCPs) to meet the requirements
of this contract. Health care providers designated by the Contractor as PCPs shall be licensed in Arizona as allopathic or osteopathic physicians who generally specialize in family practice, internal medicine, obstetrics, gynecology, or pediatrics;
certified nurse practitioners or certified nurse midwives; or physician’s assistants [42 CFR 438.206(b)(2)]. 
 The Contractor shall assess the
PCP’s ability to meet AHCCCS appointment availability and other standards when determining the appropriate number of its members to be assigned to a PCP. The Contractor shall adjust the size of a PCP’s panel, as needed, for the PCP to meet
AHCCCS appointment and clinical performance standards. AHCCCS shall inform the Contractor when a PCP has a panel of more than 1,800 AHCCCS members, to assist in the assessment of the size of their panel. This information will be provided on a
quarterly basis. 
 The Contractor shall have a system in place to monitor and ensure that each member is assigned to an individual PCP and that the
Contractor’s data regarding PCP assignments is current. The Contractor is encouraged to assign members with complex medical conditions, who are age 12 and younger, to board certified pediatricians. PCPs with assigned members diagnosed with AIDS
or as HIV positive, shall meet criteria and standards set forth in the AMPM. 
 The Contractor shall ensure that providers serving EPSDT-aged members
utilize AHCCCS-approved EPSDT Tracking forms and standardized developmental screening tools and are trained in the use of the tools. EPSDT-aged members shall be assigned to providers who are trained on and who use AHCCCS approved developmental
screening tools. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

77 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 The Contractor shall offer members freedom of choice within its network in selecting a PCP consistent with 42
CFR 438.6(m) and 438.52(d) and this contract. Any American Indian who is enrolled with the Contractor and who is eligible to receive services from a participating I/T/U provider may elect that I/T/U as his or her primary care provider, if that I/T/U
participates in the network as a primary care provider and has capacity to provide the services per ARRA Section 5006(d) and SMD letter 10-001).xiii The Contractor may restrict this choice
when a member has shown an inability to form a relationship with a PCP, as evidenced by frequent changes, or when there is a medically necessary reason. When a new member has been assigned to the Contractor, the Contractor shall inform the member in
writing of his enrollment and of his PCP assignment within 12 business days of the Contractor’s receipt of notification of assignment by AHCCCS. See ACOM Policy 404. 

At a minimum, the Contractor shall hold the PCP responsible for the following activities [42 CFR 438.208(b)(1)]: 

 

	a.	Supervising, coordinating and providing care to each assigned member (except for well woman exams and children’s dental services when provided without a PCP referral); 


 

	b.	Initiating referrals for medically necessary specialty care; 

  

	c.	Maintaining continuity of care for each assigned member; 

  

	d.	Maintaining the member’s medical record, including documentation of all services provided to the member by the PCP, as well as any specialty or referral services including behavioral health; 


 

	e.	Utilizing the AHCCCS approved EPSDT Tracking form; 

  

	f.	Providing clinical information regarding member’s health and medications to the treating provider (including behavioral health providers) within 10 business days of a request from the provider; and


  

	g.	If serving children, for enrolling as a Vaccines for Children (VFC) provider. 

 The Contractor shall establish
and implement policies and procedures to monitor PCP activities and to ensure that PCPs are adequately notified of, and receive documentation regarding, specialty and referral services provided to assigned members by specialty physicians, and other
health care professionals. 
 31. MATERNITY CARE PROVIDER STANDARDS 

The Contractor shall ensure that a maternity care provider is designated for each pregnant member for the duration of her pregnancy and postpartum care and
that those maternity services are provided in accordance with the AMPM. The Contractor may include in its provider network the following maternity care providers: 
  

	a.	Arizona licensed allopathic and/or osteopathic physicians who are obstetricians or general practice/family practice providers who provide maternity care services 


 

	b.	Physician Assistants 

  

	c.	Nurse Practitioners 

  

	d.	Certified Nurse Midwives 

  

	e.	Licensed Midwives 

 Pregnant members may choose, or be assigned, a PCP who provides obstetrical care. Such
assignment shall be consistent with the freedom of choice requirements for selecting health care professionals while ensuring that the continuity of care is not compromised. Members receiving maternity services from a certified nurse midwife or a
licensed midwife must also be assigned to a PCP for other health care and medical services. A certified nurse midwife may provide primary care services that he or she is willing to provide and that the member elects to receive from the certified
nurse midwife. Members receiving care from a certified nurse midwife may elect to receive some or all of her primary care from the assigned PCP. Licensed midwives may not provide any additional medical services as primary care is not within their
scope of practice. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

78 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 All physicians and certified nurse midwives who perform deliveries shall have hospital privileges for
obstetrical services. Practitioners performing deliveries in alternate settings shall have a documented hospital coverage agreement. Licensed midwives perform deliveries only in the member’s home. Labor and delivery services may be provided in
the member’s home by physicians, nurse practitioners, and certified nurse midwives who include such services within their practice. 
 32. REFERRAL
MANAGEMENT PROCEDURES AND STANDARDS 
 The Contractor shall have adequate written procedures regarding referrals to specialists, to include, at a
minimum, the following: 
 Use of referral forms clearly identifying the Contractor; 

 

	a.	A process in place that ensures the member’s PCP receives all specialist and consulting reports and a process to ensure PCP follow-up of all referrals including EPSDT referrals for behavioral health services;


  

	b.	A referral plan for any member who is about to lose eligibility and who requests information on low-cost or no-cost health care services; 


 

	c.	Referral to Medicare; 

  

	d.	Women shall have direct access to in-network gynecological providers, including physicians, physician assistants and nurse practitioners within the scope of their practice [42 CFR 438.206(b)(2)]; 


 

	e.	For members with special health care needs determined to need a specialized course of treatment or regular care monitoring, the Contractor must have a mechanism in place to allow such members to directly access a
specialist (for example through a standing referral or an approved number of visits) as appropriate for the member’s condition and identified needs; and 

  

	f.	Allow for a second opinion from a qualified health care professional within the network, or if one is not available in network, arrange for the member to obtain one outside the network, at no cost to the member [42 CFR
438.206(b)(3)]. 

 The Contractor shall comply with all applicable physician referral requirements and conditions defined in Sections 1903(s)
and 1877 of the Social Security Act and their implementing regulations which include, but are not limited to, 42 CFR Part 411, Part 424, Part 435 and Part 455. Sections 1903(s) and 1877 of the Act prohibits physicians from making referrals for
designated health services to health care entities with which the physician or a member of the physician’s family has a financial relationship. Designated health services include: 

 

	a.	Clinical laboratory services 

  

	b.	Physical therapy services 

  

	c.	Occupational therapy services 

  

	d.	Radiology services 

  

	e.	Radiation therapy services and supplies 

  

	f.	Durable medical equipment and supplies 

  

	g.	Parenteral and enteral nutrients, equipment and supplies 

  

	h.	Prosthetics, orthotics and prosthetic devices and supplies 

  

	i.	Home health services 

  

	j.	Outpatient prescription drugs 

  

	k.	Inpatient and outpatient hospital services 

 33. APPOINTMENT STANDARDS 

The Contractor shall actively monitor and track provider compliance with appointment availability standards as required in ACOM Policy 417 [42 CFR 438.206].

 The Contractor is required on a quarterly basis to conduct review of the availability of the below listed providers in sufficient quantity to ensure
results are meaningful and representative of the Contractor’s network. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

79 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 For purposes of this section, “urgent” is defined as an acute, but not necessarily life-threatening
disorder, which, if not attended to, could endanger the patient’s health. The Contractor shall have procedures in place that ensure the following standards are met. 

For Primary Care Provider Appointments, the Contractor shall be able to provide: 

 

	a.	Emergency appointments the same day or within 24 hours of the member’s phone call or other notification 

  

	b.	Urgent care appointments within 2 days of request 

  

	c.	Routine care appointments within 21 days of request 

 For Specialty Provider Referrals, the
Contractor shall be able to provide: 
  

	a.	Emergency appointments within 24 hours of referral 

  

	b.	Urgent care appointments within 3 days of referral 

  

	c.	Routine care appointments within 45 days of referral 

 For Dental Provider Appointments, the
Contractor shall be able to provide: 
  

	a.	Emergency appointments within 24 hours of request 

  

	b.	Urgent care appointments within 3 days of request 

  

	c.	Routine care appointments within 45 days of request 

 For Maternity Care Provider Appointments,
the Contractor shall be able to provide initial prenatal care appointments for enrolled pregnant members as follows: 
  

	a.	First trimester - within 14 days of request 

  

	b.	Second trimester - within 7 days of request 

  

	c.	Third trimester - within 3 days of request 

  

	d.	High risk pregnancies - within 3 days of identification of high risk by the Contractor or maternity care provider, or immediately if an emergency exists 


ADULT DUAL MEMBERS RECEIVING GENERAL MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES 

For Behavioral Health Provider Appointments, the Contractor shall be able to provide: 

 

	a.	Emergency appointments the same day or within 24 hours of the referral or request 

  

	b.	Appointment for initial assessment within 7 days of referral 

  

	c.	Appointment for ongoing services within 23 days of initial assessment 

 For wait time in the office, the
Contractor shall actively monitor and ensure that a member’s waiting time for a scheduled appointment at the PCP’s or specialist’s office is no more than 45 minutes, except when the provider is unavailable due to an emergency. 

For medically necessary non-emergent transportation, the Contractor shall schedule transportation so that the member arrives on time for the
appointment, but no sooner than one hour before the appointment; nor have to wait more than one hour after the conclusion of the treatment for transportation home; nor be picked up prior to the completion of treatment. Also see Section D, Paragraph
11, Special Health Care Needs. The Contractor must develop and implement a quarterly performance auditing protocol to evaluate compliance with the standards above for all subcontracted transportation vendors/brokers and require corrective action if
standards are not met. 
 The Contractor must use the results of appointment standards monitoring to assure adequate appointment availability in order to
reduce unnecessary emergency department utilization. The Contractor is also encouraged to contract with or employ the services of non-emergency facilities to address member non-emergency care issues occurring after regular office hours or on
weekends. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

80 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 The Contractor shall establish processes to monitor and reduce the appointment “no-show” rate by
provider and service type. As best practices are identified, AHCCCS may require implementation by the Contractor. 
 The Contractor shall have written
policies and procedures about educating its provider network regarding appointment time requirements. The Contractor must develop a corrective action plan when appointment standards are not met. In addition, the Contractor must develop a corrective
action plan in conjunction with the provider when appropriate [42 CFR 438.206(c)(1)(iv), (v) and (vi)]. Appointment standards shall be included in the Provider Manual. The Contractor is encouraged to include the standards in the provider
subcontracts. 
 34. FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS 

The Contractor is encouraged to use Federally Qualified Health Centers and Rural Health Clinics (FQHCs/RHCs) and FQHC Look-Alikes in Arizona to provide covered
services. FQHCs/RHCs and FQHC Look-Alikes are paid unique, cost-based Prospective Payment System (PPS) rates for non-pharmacy ambulatory Medicaid-covered services. The PPS rate is an all-inclusive per visit rate.xiv 
 To ensure compliance with the requirement of 42 USC 1396b(m)(2)(A)(ix) that the Contractor’s
payments, in aggregate, will not be less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a provider which is not a FQHC or
RHC:xv 
  

	1.	For dates of service from October 1, 2014 through March 31, 2015, the Contractor shall negotiate rates of payment with FQHCs/RHCs and FQHC Look-Alikes for non-pharmacy ambulatory services that are comparable
to the rates paid to providers that provide similar services. 

  

	2.	For dates of service on and after April 1, 2015, the Contractor shall pay the unique PPS rates, or negotiate sub-capitated agreements comparable to the unique PPS rates, to FQHCs/RHCs and FQHC Look-Alikes for
PPS-eligible visits. 

 AHCCCS reserves the right to review a Contractor’s rates with an FQHC/RHC and FQHC Look-Alikes for reasonableness
and to require adjustments when rates are found to be substantially less than those being paid to other, non-FQHC/RHC/FQHC Look-Alikes providers for comparable services, or not equal to or substantially less than the PPS rates. 

For FQHC and FQHC Look-Alike pharmacies, all drugs identified in the 340B Drug Pricing Program are required to be billed at the lesser of: 1) the actual
acquisition cost of the drug or 2) the 340B ceiling price. These drugs shall be reimbursed at the lesser of the two amounts above plus a dispensing fee. See AHCCCS rule A.A.C. R9-22-710 (C) for further details. 

The Contractor may be required to submit member information for Title XIX and Title XXI members for each FQHC/RHC/FQHC Look-Alikes as specified in Attachment
F3, Contractor Chart of Deliverables. AHCCCS will perform periodic audits of the member information submitted. The Contractor should refer to the AHCCCS Financial Reporting Guide for Acute Care Contractors with the Arizona Health Care Cost
Containment System for further guidance. The FQHCs/RHCs/FQHC Look-Alikes registered with AHCCCS are listed on the AHCCCS website. 
 35. PROVIDER MANUAL

 The Contractor shall develop, distribute and maintain a provider manual as described in ACOM Policy 416. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

81 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 36. PROVIDER REGISTRATION 

The Contractor shall ensure that all of its subcontractors register with AHCCCS as an approved service provider. For specific requirements on Provider
Registration refer to the AHCCCS website at: 
 http://www.azahcccs.gov/commercial/ProviderRegistration/registration.aspx. 

The National Provider Identifier (NPI) is required on all claim submissions and subsequent encounters from providers who are eligible for an NPI. The
Contractor shall work with providers to obtain their NPI. 
 Except as otherwise required by law or as otherwise specified in a contract between a
Contractor and a provider, the AHCCCS Fee-For-Service provisions referenced in the AHCCCS Provider Participation Agreement located on the AHCCCS website (e.g. billing requirements, coding standards, payment rates) are in force between the provider
and Contractor. 
 37. SUBCONTRACTS 
 The Contractor
shall be legally responsible for contract performance whether or not subcontracts are used [42 CFR 438.230(a) and 434.6(c)]. No subcontract shall operate to terminate the legal responsibility of the Contractor to assure that all activities carried
out by the subcontractor conform to the provisions of this contract. The Contractor shall be held fully liable for the performance of all contract requirements and shall develop and maintain a system for regular and periodic assessment of all
subcontractors’ compliance with its terms. Subject to such conditions, any function required to be provided by the Contractor pursuant to this contract may be subcontracted to a qualified person or organization [42 CFR 438.6]. All such
subcontracts must be in writing [42 CFR 438.6(l)]. All subcontracts entered into by the Contractor are subject to prior review and written approval by AHCCCS, Division of Health Care Management, and shall incorporate by reference the applicable
terms and conditions of this contract. 
 Before entering into a subcontract which delegates duties or responsibilities to a subcontractor the Contractor
must evaluate the prospective subcontractor’s ability to perform the activities to be delegated. If the Contractor delegates duties or responsibilities then the Contractor shall establish a written agreement that specifies the activities and
reporting responsibilities delegated to the subcontractor. The written agreement shall also provide for revoking delegation or imposing other sanctions if the subcontractor’s performance is inadequate. The Contractor’s local CEO must
retain the authority to direct and prioritize any delegated contract requirements. In order to determine adequate performance, the Contractor shall monitor the subcontractor’s performance on an ongoing basis and subject it to formal review at
least annually or more frequently if requested by AHCCCS. As a result of the performance review, any deficiencies must be communicated to the subcontractor in order to establish a corrective action plan [42 CFR 438.230(b)]. The results of the
performance review and the correction plan shall be communicated to AHCCCS upon completion. 
 The Contractor shall maintain a fully executed original or
electronic copy of all subcontracts, which shall be accessible to AHCCCS within five business days of the request by AHCCCS. All requested subcontracts must have full disclosure of all terms and conditions and must fully disclose all financial or
other requested information. Information may be designated as confidential but may not be withheld from AHCCCS as proprietary. Information designated as confidential may not be disclosed by AHCCCS without the prior written consent of the Contractor
except as required by law. All subcontracts shall comply with the applicable provisions of Federal and State laws, regulations and policies. 
 AHCCCS may,
at its discretion, communicate directly with the governing body or Parent Corporation of the Contractor regarding the performance of a subcontractor or Contractor respectively. 

Minimum Subcontract Provisions: All subcontracts must reference and require compliance with the Minimum Subcontract Provisions. See Minimum
Subcontract Provisions on the AHCCCS Website at: 
 http://www.azahcccs.gov/commercial/MinimumSubcontractProvisions.aspx 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

82 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 In addition, each subcontract must contain the following: 

 

	1.	Full disclosure of the method and amount of compensation or other consideration to be received by the subcontractor; 

  

	2.	Identification of the name and address of the subcontractor; 

  

	3.	Identification of the population, to include patient capacity, to be covered by the subcontractor; 

  

	4.	The amount, duration and scope of medical services to be provided, and for which compensation will be paid; 

  

	5.	The term of the subcontract including beginning and ending dates, methods of extension, termination and re-negotiation; 

  

	6.	The specific duties of the subcontractor relating to coordination of benefits and determination of third-party liability; 


 

	7.	A provision that the subcontractor agrees to identify Medicare and other third-party liability coverage and to seek such Medicare or third party liability payment before
submitting claims to the Contractor; 

  

	8.	A description of the subcontractor’s patient, medical, dental and cost record keeping system; 

  

	9.	Specification that the subcontractor shall cooperate with quality management programs, and comply with the utilization control and review procedures specified in 42 CFR Part 456, as specified in the AMPM;


  

	10.	A provision stating that a merger, reorganization or change in ownership of an Administrative Services subcontractor of the Contractor shall require a contract amendment and prior approval of AHCCCS; 


 

	11.	A provision that indicates that AHCCCS is responsible for enrollment, re-enrollment and disenrollment of the covered population; 


 

	12.	A provision that the subcontractor shall be fully responsible for all tax obligations, Worker’s Compensation Insurance, and all other applicable insurance coverage obligations which arise under this subcontract,
for itself and its employees, and that AHCCCS shall have no responsibility or liability for any such taxes or insurance coverage; 

  

	13.	A provision that the subcontractor must obtain any necessary authorization from the Contractor or AHCCCS for services provided to eligible and/or enrolled members; 


 

	14.	A provision that the subcontractor must comply with encounter reporting and claims submission requirements as described in the subcontract; 


 

	15.	Provision(s) that allow the Contractor to suspend, deny, refuse to renew or terminate any subcontractor in accordance with the terms of this contract and applicable law and regulation; 


 

	16.	A provision that the subcontractor may provide the member with factual information, but is prohibited from recommending or steering a member in the member’s selection of a Contractor; and 


 

	17.	A provision that compensation to individuals or entities that conduct utilization management and concurrent review activities is not structured so as to provide incentives for the individual or entity to deny, limit or
discontinue medically necessary services to any enrollee [42 CFR 438.210(e)]. 

 In the event of a modification to the AHCCCS Minimum
Subcontract Provisions the Contractor shall issue a notification of the change to its subcontractors within 30 days of the published change and ensure amendment of affected subcontracts. Affected subcontracts shall be amended on their regular
renewal schedule or within six calendar months of the update, whichever comes first. See also ACOM Policy 416. 
 Administrative Services
Subcontracts: Administrative Services subcontracts shall be submitted to AHCCCS, Division of Health Care Management for prior approval as specified in ACOM Policy 438 and Attachment F3, Contractor Chart of Deliverables. If at any time during
the period of the subcontract, the subcontractor is found to be in non-compliance, the Contractor shall notify AHCCCS as specified in ACOM Policy 438 and Attachment F3, Contractor Chart of Deliverables. The Contractor will submit this in writing and
provide the corrective action plan and any measures taken by the Contractor to bring the subcontractor into compliance. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

83 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 The Contractor must submit an annual Administrative Services Subcontractor Evaluation Report as specified in
ACOM Policy 438 and Attachment F3, Contractor Chart of Deliverables. The report shall include any findings of subcontract non-compliance and any corrective action plans and/or measures taken by the Contractor to bring the subcontractor into
compliance. 
 The Contractor shall require Administrative Services Subcontractors to adhere to screening and disclosure requirements as described in
Paragraph 62, Corporate Compliance. 
 A merger, acquisition, reorganization or change in ownership of an Administrative Services subcontractor of the
Contractor requires prior approval of AHCCCS, as outlined in ACOM Policy 438. 
 AHCCCS will not permit one organization to own or manage more than one
contract within the same program in the same GSA. 
 Provider Agreements: The Contractor shall not include covenant-not-to-compete
requirements in its provider agreements. Specifically, the Contractor shall not contract with a provider and require that the provider not provide services for any other AHCCCS Contractor. In addition, the Contractor shall not enter into
subcontracts that contain compensation terms that discourage providers from serving any specific eligibility category. 
 The Contractor must make
reasonable efforts to enter into a written agreement with any provider providing services at the request of the Contractor more than 25 times during the previous contract year and/or are anticipated to continue providing services for the Contractor.
The Contractor must follow ACOM Policy 415 and consider the repeated use of providers operating without a written agreement when assessing the adequacy of its network. 

For all subcontracts in which the Contractor and subcontractor have a capitated arrangement/risk sharing arrangement, the following provision must be included
verbatim in every contract: 
 If <the Subcontractor> does not bill <the Contractor>, < the subcontractor’s> encounter
data that is required to be submitted to <the Contractor> pursuant to contract is defined for these purposes as a “claim for payment”. <The Subcontractor’s> provision of any service results in a “claim for
payment” regardless of whether there is any intention of payment. All said claims shall be subject to review under any and all fraud and abuse statutes, rules and regulations, including but not limited to Arizona Revised Statute (A.R.S.)
§36-2918. 
 38. CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM 

The Contractor shall develop and maintain claims processes and systems that ensure the accurate collection and processing of claims, analysis, integration, and
reporting of data. These processes and systems shall result in information on areas including, but not limited to, service utilization, claim disputes and appeals [42 CFR 438.242(a)]. 

General Claims Processing Requirements 
 The Contractor
must include nationally recognized methodologies to correctly pay claims including but not limited to: 
  

	a.	Medicaid Correct Coding Initiative (NCCI) for Professional, ASC and Outpatient services 

  

	b.	Multiple Procedure/Surgical Reductions 

  

	c.	Global Day E & M Bundling standards 

 The Contractor’s claims payment system must be able to assess
and/or apply data related edits including but not limited to: 
  

	a.	Benefit Package Variations 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

84 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	b.	Timeliness Standards 

  

	c.	Data Accuracy 

  

	d.	Adherence to AHCCCS Policy 

  

	e.	Provider Qualifications 

  

	f.	Member Eligibility and Enrollment 

  

	g.	Over-Utilization Standards 

 The Contractor must produce a remittance advice related to the Contractor’s
payments and/or denials to providers and each must include at a minimum: 
  

	a.	The reason(s) for denials and adjustments 

  

	b.	A detailed explanation/description of all denials, payments and adjustments 

  

	c.	The amount billed 

  

	d.	The amount paid 

  

	e.	Application of COB and copays 

  

	f.	Provider rights for claim disputes 

 Additionally, the Contractor must include information in its remittance
advice which informs providers of instructions and timeframes for the submission of claim disputes and corrected claims. All paper remittance advices must describe this information in detail. Electronic remittance advices must either direct
providers to the link where this information is explained or include a supplemental file where this information is explained. 
 The related remittance
advice must be sent with the payment, unless the payment is made by electronic funds transfer (EFT). Any remittance advice related to an EFT must be sent to the provider, no later than the date of the EFT. See Section D, Paragraph 64, Systems and
Data Exchange Requirements, for specific standards related to remittance advice and EFT payment. 
 AHCCCS requires the Contractor to attend and participate
in AHCCCS workgroups including Technical Consortium meetings to review upcoming initiatives and other technical issues. 
 Per A.R.S. §36-2904, unless
a shorter time period is specified in contract, the Contractor shall not pay a claim initially submitted more than six months after the date of service or date of eligibility posting whichever is later, or pay a clean claim submitted more than 12
months after date of service or date of eligibility posting, whichever is later; except as directed by AHCCCS or otherwise noted in this contract. Regardless of any subcontract with an AHCCCS Contractor, when one AHCCCS Contractor recoups a claim
because the claim is the payment responsibility of another AHCCCS Contractor (responsible Contractor), the provider may file a claim for payment with the responsible Contractor. The responsible Contractor shall not deny a claim on the basis of lack
of timely filing if the provider submits a clean claim to the responsible Contractor no later than 60 days from the date of the recoupment, 12 months from the date of service, or 12 months from date that eligibility is posted, whichever date is
later. 
 Claim payment requirements pertain to both contracted and non-contracted providers. The receipt date of the claim is the date stamp on the claim
or the date electronically received. The receipt date is the day the claim is received at the Contractor’s specified claim mailing address, received through direct electronic submission to the Contractor, or received by the Contractor’s
designated Clearinghouse. The paid date of the claim is the date on the check or other form of payment [42 CFR 447.45(d)]. Claims submission deadlines shall be calculated from the claim end date of service, inpatient claim date of discharge or the
effective date of eligibility posting, whichever is later as stated in A.R.S. §36-2904. Additionally, unless a subcontract specifies otherwise, the Contractor shall ensure that for each form type (Dental/Professional/Institutional), 95% of all
clean claims are adjudicated within 30 days of receipt of the clean claim and 99% are adjudicated within 60 days of receipt of the clean claim. 
 In
accordance with the Deficit Reduction Act of 2005, Section 6085, SMD letter 06-010, and Section 1932 (b)(2)(D) of the Social Security Act, the Contractor is required to reimburse non-contracted emergency services providers at the AHCCCS
Fee-For-Service rate. This applies to in State as well as out of State providers.xvi 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

85 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 In accordance with A.R.S. §36-2904 the Contractor is required to reimburse providers of hospital and non
hospital services at the AHCCCS fee schedule in the absence of a contract or negotiated rate. This requirement applies to services which are directed out of network by the Contractor or to emergency services. For inpatient stays at urban hospitals
pursuant to A.R.S. §36-2905.01 for non-emergency services, the Contractor is required to reimburse non-contracted providers at 95% of the AHCCCS fee schedule specified in A.R.S. §36-2903.01. All payments are subject to other limitations
that apply, such as provider registration, prior authorization, medical necessity, and covered service. 
 The Contractor is required to reimburse providers
for previously denied or recouped claims if the provider was subsequently denied payment by the primary insurer based on timely filing limits or lack of prior authorization and the member failed to initially disclose additional insurance coverage
other than AHCCCS. 
 The provider shall have 90 days from the date they become aware that payment will not be made to submit a new claim to the Contractor
which includes the documentation from the primary insurer that payment will not be made. Documentation includes but is not limited to any of the following items establishing that the primary insurer has or would deny payment based on timely filing
limits or lack of prior authorization; an EOB, policy or procedure, Provider Manual excerpt, etc. 
 For hospital clean claims, in the absence of a contract
specifying otherwise, a Contractor shall apply a quick pay discount of 1% on claims paid within 30 days of receipt of the clean claim. For hospital clean claims, in the absence of a contract specifying other late payment terms, a Contractor is
required to pay slow payment penalties (interest) on payments made after 60 day of receipt of the clean claim. Interest shall be paid at the rate of 1% per month for each month or portion of a month from the 61st day until the date of payment
(A.R.S. §36-2903.01). 
 For all non-hospital clean claims, in the absence of a contract specifying other late payment terms, a Contractor is required
to pay interest on payments made after 45 days of receipt of the clean claim (as defined in this contract). Interest shall be at the rate of 10% per annum (prorated daily) from the 46th day
until the date of payment. 
 In the absence of a contract specifying other late payment terms, a claim for an authorized service submitted by a licensed
skilled nursing facility, assisted living ALTCS provider or a home and community based ALTCS provider shall be adjudicated within 30 calendar days after receipt by the Contractor. A Contractor is required to pay interest on payments made after 30
days of receipt of the clean claim. Interest shall be paid at the rate of 1% per month (prorated on a daily basis) from the date the clean claim is received until the date of payment (A.R.S. §36- 2943.D). 

The Contractor shall pay interest on all claim disputes as appropriate based on the date of the receipt of the original clean claim submission (not the claim
dispute). 
 When interest is paid, the Contractor must report the interest as directed in the AHCCCS Encounter Manual and the AHCCCS Claims Dashboard
Reporting Guide. 
 See ACOM Policy 203 for additional information regarding requirements for the adjudication and payment of claims. 

Recoupments: The Contractor’s claims processes, as well as its prior authorization and concurrent review process, must minimize the
likelihood of having to recoup already-paid claims. 
 Any individual recoupment in excess of $50,000 per provider, or Tax Identification Number within a
contract year or greater than 12 months after the date of the original payment must be approved as specified in Attachment F3, Contractor Chart of Deliverables and as further described in ACOM Policy 412. Upon submission of a request for approval,
AHCCCS will respond within 30 days of the recoupment request. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

86 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 When recoupment amounts for a Provider TIN cumulatively exceed $50,000 during a contract year (based on
recoupment date), the Contractor must report the cumulative recoupment monthly to the designated AHCCCS Operations and Compliance Officer as outlined in the AHCCCS Claims Dashboard Reporting Guide and Attachment F3, Contractor Chart of Deliverables.

 The Contractor must void encounters for claims that are recouped in full. For recoupments that result in a reduced claim value or adjustments that result
in an increased claim value, replacement encounters must be submitted. AHCCCS may validate the submission of applicable voids and replacement encounters upon completion of any approved recoupment that meets the qualifications of this section. All
replaced or voided encounters must reach adjudicated status within 120 days of the approval of the recoupment. The Contractor should refer to ACOM Policy 412 and AHCCCS Encounter Manual for further guidance. 

Appeals: If the Contractor or a Director’s Decision reverses a decision to deny, limit, or delay authorization of services, and the member
received the disputed services while an appeal was pending, the Contractor shall process a claim for payment from the provider in a manner consistent with the Contractor’s or Director’s Decision and applicable statutes, rules, policies,
and contract terms. The provider shall have 90 days from the date of the reversed decision to submit a clean claim to the Contractor for payment. For all claims submitted as a result of a reversed decision, the Contractor is prohibited from denying
claims for untimeliness if they are submitted within the 90 day timeframe. The Contractor is also prohibited from denying claims submitted as a result of a reversed decision because the member failed to request continuation of services during the
appeals/hearing process: a member’s failure to request continuation of services during the appeals/hearing process is not a valid basis to deny the claim. 

ICD-10 Readiness: In 2009 the Federal government published the final regulation that adopted the ICD-10 code sets as HIPAA standards (45 CFR
162.1002). As HIPAA covered entities, State Medicaid programs must comply with use of the ICD-10 code sets by the deadline established by CMS. The compliance date published in the final rule is October 1, 2013. However, in 2014 the compliance
effective date was further delayed to October 1, 2015, though AHCCCS did not amend its requirement that the Contractor be ready to implement ICD-10 effective October 1, 2014. 

Claims Processing Related Reporting: The Contractor shall submit a monthly Claims Dashboard as specified in the AHCCCS Claims Dashboard
Reporting Guide and Attachment F3, Contractor Chart of Deliverables. 
 AHCCCS may require the Contractor to review claim requirements, including billing
rules and documentation requirements, and submit a report to AHCCCS that will include the rationale for specified requirements. AHCCCS shall determine and provide a format for the reporting of this data at the time of the request. 

Claims System Audits: The Contractor shall develop and implement an internal ongoing claims audit function that will include, at a minimum, the
following: 
  

	a.	Verification that provider contracts are loaded correctly 

  

	b.	Accuracy of payments against provider contract terms 

 Audits of provider contract terms must be performed on a
regular and periodic basis and consist of a random, statistically significant sampling of all contracts in effect at the time of the audit. The audit sampling methodology must be documented in policy and the Contractor should review the contract
loading of both large groups and individual practitioners at least once every five year period in addition to any time a contract change is initiated during that timeframe. The findings of the audits described above must be documented and any
deficiencies noted in the resulting reports must be met with corrective action. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

87 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 In addition, in the event of a system change or upgrade, as specified in Attachment F3, Contractor Chart of
Deliverables, the Contractor may also be required to initiate an independent audit of the Claim Payment/Health Information System. The Division of Health Care Management will approve the scope of this audit, and may include areas such as a
verification of eligibility and enrollment information loading, contract information management (contract loading and auditing), claims processing and encounter submission processes, and will require a copy of the final audit findings. 

Recovery Audit Contractor Audits: A Recovery Audit Contractor (RAC) is a private entity that is contracted to identify underpayments and
overpayments, and to recoup overpayments made to providers. The Affordable Care Act of 2010 required States to establish Medicaid RAC programs. CMS promulgated rules regarding the implementation of the Medicaid RAC requirements (42 CFR 455.500 et
seq.), including the provision that Medicaid RACs are only required to review Fee-For-Service claims until a permanent Medicare managed care RAC program is fully operational or a viable State managed care model is identified and CMS undertakes rules
regarding managed care RAC efforts. 
 AHCCCS is exploring what opportunities may exist in the marketplace regarding a methodology for conducting a recovery
audit of its services delivered through its managed care contracts (excluding reinsurance). The Contractor shall participate in any RAC activities mandated by AHCCCS, via contract amendment or policy, upon determination of the method of approach.

 39. SPECIALTY CONTRACTS 
 AHCCCS may at any time
negotiate or contract on behalf of the Contractor and AHCCCS for specialized hospital and medical services. AHCCCS will consider existing Contractor resources in the development and execution of specialty contracts. AHCCCS may require the Contractor
to modify its delivery network to accommodate the provisions of specialty contracts. AHCCCS may consider waiving this requirement in particular situations if such action is determined to be in the best interest of the State; however, in no case
shall reimbursement exceeding that payable under the relevant AHCCCS specialty contract be considered in capitation rate development or risk sharing arrangements, including reinsurance. 

During the term of specialty contracts, AHCCCS may act as an intermediary between the Contractor and specialty Contractors to enhance the cost effectiveness
of service delivery, medical management, and adjudication of claims related to payments provided under specialty contracts shall remain the responsibility of the Contractor. AHCCCS may provide technical assistance prior to the implementation of any
specialty contracts. 
 AHCCCS has specialty contracts, including but not limited to, transplant services, anti-hemophilic agents and pharmaceutical related
services. AHCCCS shall provide at least 60 days advance written notice to the Contractor prior to the implementation of any specialty contract. 
 40.
HOSPITAL SUBCONTRACTING AND REIMBURSEMENT 
 In the absence of a contract between the Contractor and a hospital providing otherwise, the Contractor shall
reimburse hospitals for inpatient and outpatient hospital services as required by A.R.S. §§36-2904 and 2905.01, and 9 A.A.C. 22, Article 7, which includes without limitation: reimbursement of the majority of inpatient hospital services
with discharge dates on and after October 1, 2014, using the APR-DRG payment methodology in A.A.C. R9-22-712.60 through A.A.C. R9-22-712.81; reimbursement of limited inpatient hospital services with discharge dates on and after October 1,
2014, using per diem rates described in A.A.C. R9-22-712.61; and, in Pima and Maricopa Counties, payment to non-contracted hospitals at 95% of the amounts otherwise payable for inpatient services. 

The Contractor is encouraged to obtain subcontracts with hospitals in all GSAs. A Contractor serving out-of-state border communities (excluding Mexico) is
strongly encouraged to establish contractual agreements with those out-of-state hospitals in counties that are identified by GSA in ACOM Policy 436. The Contractor, upon request, shall make available to AHCCCS, all hospital subcontracts and
amendments. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

88 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 The Contractor may conduct prepayment and post-payment medical reviews of all hospital claims including
outlier claims. Erroneously paid claims are subject to recoupment. If the Contractor fails to identify lack of medical necessity through concurrent review and/or prepayment medical review, lack of medical necessity identified during
post-payment medical review shall not constitute a basis for recoupment by the Contractor. See also Section D, Paragraph 38, Claims Payment/Health Information System. 

41. RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT 

The Contractor shall provide medically necessary nursing facility services as outlined in Section D, Paragraph 10, Scope of Services. The Contractor shall also
provide medically necessary nursing facility services for any enrolled member who has a pending ALTCS application who is currently residing in a nursing facility and is eligible for services provided under this contract. If the member becomes ALTCS
eligible and is enrolled with an ALTCS Contractor before the end of the maximum 90 days per contract year of nursing facility coverage, the Contractor is only responsible for nursing facility reimbursement during the time the member is enrolled with
the Contractor as shown in the PMMIS. Nursing facility services covered by another liable party (including Medicare) while the member is enrolled with the Contractor, shall be applied to the 90 day per contract year limitation. 

The Contractor shall not deny nursing facility services when the member’s eligibility, including prior period coverage, had not been posted at the time
of admission. In such situations the Contractor shall impose reasonable authorization requirements. There is no ALTCS enrollment, including prior period coverage that occurs concurrently with AHCCCS acute enrollment. 

The Contractor shall notify the Assistant Director of the Division of Member Services when a member has been residing in a nursing facility, alternative
residential facility or receiving home and community based services for 45 days as specified in Section D, Paragraph 10, Scope of Services, under the heading Nursing Facility. This will allow AHCCCS time to follow-up on the status of the
ALTCS application and to consider potential Fee-For-Service coverage if the stay goes beyond the 90 day per contract year maximum. 
 42. INCENTIVES/PAY
FOR PERFORMANCE 
 Physician Incentives 
 The
Contractor must comply with all applicable physician incentive requirements and conditions defined in 42 CFR 417.479. These regulations prohibit physician incentive plans that directly or indirectly make payments to a doctor or a group as an
inducement to limit or refuse medically necessary services to a member. The reporting requirements under 42 CFR 417.479 have been suspended. No reporting to CMS is required until the suspension is lifted. 

The Contractor shall disclose to AHCCCS the information on physician incentive plans listed in 42 CFR 417.479(h)(1) through 417.479(i) upon request from
AHCCCS or CMS and to AHCCCS members who request them. AHCCCS shall also review the Value-Based Purchasing (VBP) deliverables required under Section D, Paragraph 76, and may request supplemental information from the Contractor in fulfillment of
the requirements in 42 CFR 417.479(h)(1) through 417.479(i). 
 The Contractor shall not enter into contractual arrangements that place providers at
substantial financial risk as defined in 42 CFR 417.479 unless specifically approved in advance by the AHCCCS, Division of Health Care Management. In order to obtain approval when the contractual arrangements meet the definition of substantial
financial risk, the following must be submitted to the AHCCCS, Division of Health Care Management 45 days prior to the implementation of the contract as specified in Attachment F3, Contractor Chart of Deliverables, [42 CFR 438.6(g)]: 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

89 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	1.	The type of incentive arrangement 

  

	2.	A plan for the member satisfaction survey; 

  

	3.	Details of the stop-loss protection provided; 

  

	4.	A summary of the compensation arrangement that meets the substantial financial risk definition; and 

  

	5.	Any other items as requested by AHCCCS 

 Any Contractor-selected and/or developed pay for performance
initiative that meets the requirements of 42 CFR 417.479 must be approved by AHCCCS, Division of Health Care Management prior to implementation as specified in Attachment F3, Contractor Chart of Deliverables. 

The Contractor shall also comply with all physician incentive plan requirements as set forth in 42 CFR 422.208, 422.210 and 438.6(h). These regulations
apply to contract arrangements with subcontracted entities that provide utilization management services. 
 43. MANAGEMENT SERVICES AGREEMENT AND COST
ALLOCATION PLAN 
 If a Contractor has subcontracted for management services, the management service agreement must be approved in advance by AHCCCS,
Division of Health Care Management. If there is a cost allocation plan as part of the management services agreement, it is subject to review by AHCCCS as specified in Attachment F3, Contractor Chart of Deliverables. AHCCCS reserves the right to
perform a thorough review of actual management fees charged and/or corporate allocations made. 
 If there is a change in ownership of the entity with which
the Contractor has contracted for management services, AHCCCS must review and provide prior approval of the assignment of the subcontract to the new owner. AHCCCS may offer open enrollment to the members assigned to the Contractor should a change in
ownership occur. AHCCCS will not permit two Acute Care Contractors to utilize the same management service company in the same GSA. 
 The performance of
management service subcontractors must be evaluated and included in the Annual Subcontractor Assignment and Evaluation Report required by Section D, Paragraph 37, Subcontracts and as specified in Attachment F3, Contractor Chart of Deliverables. 

44. MATERIAL CHANGE TO BUSINESS OPERATIONS 
 The
Contractor is responsible for evaluating all operational changes, including unexpected or significant changes, and determining whether those changes are material changes to the Contractor’s business operations [42 CFR 438.207 (c)]. All material
changes to the business operations must be approved in advance by AHCCCS, Division of Health Care Management. A material change to business operations is defined as any change in overall business operations (e.g., policy, process, protocol, such as
prior authorization or retrospective review) that affects, or can reasonably be foreseen to affect, the Contractor’s ability to meet the performance standards as described in this contract including, but not limited to, any changes that would
impact or is likely to impact more than 5% of total membership and/or provider network in a specific GSA. 
 The Contractor must submit the request for
approval of a material change to business operations with information including, but not limited to, how the change will affect the delivery of covered services, the Contractor’s plans for maintaining the quality of member care, and
communications to providers and members, as outlined in ACOM Policy 439 and as specified in Attachment F3, Contractor Chart of Deliverables. AHCCCS will respond to the Contractor within 30 days of the submission. A material change in the
Contractor’s business operations requires 30 days advance written notice to providers and members. For emergency situations, AHCCCS will expedite the approval process. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

90 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 The Contractor may be required to conduct meetings with providers to address issues (or to provide general
information, technical assistance, etc.) related to Federal and State requirements, changes in policy, reimbursement matters, prior authorization and other matters as identified or requested by the AHCCCS. 

See Section D, Paragraph 29, regarding material changes by the Contractor that may impact the provider network. 

See Section D, Paragraph 64, for additional submission requirements regarding system changes and upgrades. 

45. MINIMUM CAPITALIZATION 
 The Contractor is required to
meet a minimum capitalization requirement within 30 days after contract award. Details regarding this requirement are included in AHCCCS’ solicitation, released prior to the expiration of the current contract period. Once the new contract
period commences, the minimum capitalization may be applied to the Contractor’s equity per member standard, which continues throughout the contract period. See Section D, Paragraph 50, Financial Viability Standards. 

46. PERFORMANCE BOND OR BOND SUBSTITUTE 
 In addition to
the minimum capitalization requirements, the Contractor shall be required to establish and maintain a performance bond for as long as the Contractor has liabilities of $50,000 or more outstanding, or 15 months following the termination date of this
contract, whichever is later, to guarantee: 1) payment of the Contractor’s obligations to providers, and 2) performance by the Contractor of its obligations under this contract [42 CFR 438.116]. The Performance Bond shall be in a form
acceptable to AHCCCS. See ACOM Policy 305. 
 In the event of a default by the Contractor, AHCCCS shall, in addition to any other remedies it may have under
this contract, obtain payment under the Performance Bond or substitute security for the purposes of the following: 
  

	a.	Paying any damages sustained by providers, non-contracting providers and non-providers by reason of a breach of the Contractor’s obligations under this contract; 


 

	b.	Reimbursing AHCCCS for any payments made by AHCCCS on behalf of the Contractor; and 

  

	c.	Reimbursing AHCCCS for any extraordinary administrative expenses incurred by reason of a breach of the Contractor’s obligations under this contract, including, but not limited to, expenses incurred after
termination of this contract for reasons other than the convenience of the State by AHCCCS. 

 In the event AHCCCS agrees to accept substitute
security in lieu of the security types outlined in ACOM Policy 305, the Contractor agrees to execute any and all documents and perform any and all acts necessary to secure and enforce AHCCCS’ security interest in such substitute security
including, but not limited to, security agreements and necessary UCC filings pursuant to the Arizona Uniform Commercial Code. The Contractor must request approval from AHCCCS before a substitute security in lieu of the security types outlined in
ACOM Policy 305 is established. In the event such substitute security is agreed to and accepted by AHCCCS, the Contractor acknowledges that it has granted AHCCCS a security interest in such substitute security to secure performance of its
obligations under this contract. The Contractor is solely responsible for establishing the credit-worthiness of all forms of substitute security. AHCCCS may, after written notice to the Contractor, withdraw its permission for substitute security, in
which case the Contractor shall provide AHCCCS with a form of security described in ACOM Policy 305. 
 The Contractor may not change the amount, duration
or scope of the performance bond without prior written approval from AHCCCS, Division of Health Care Management. The Contractor shall not leverage the bond for another loan or create other creditors using the bond as security. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

91 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 47. AMOUNT OF PERFORMANCE BOND 

The initial amount of the Performance Bond shall be equal to 100% of the total capitation payment expected to be paid to the Contractor in the first month of
the contract year, or as determined by AHCCCS. The total capitation amount (including delivery supplement) excludes premium tax. This requirement must be satisfied by the Contractor no later than 30 days after notification by AHCCCS of the amount
required. Thereafter, AHCCCS shall review the capitation amounts of the Contractor on a monthly basis to determine if the Performance Bond must be increased. The Contractor shall have 30 days following notification by AHCCCS to increase the amount
of the Performance Bond. The Performance Bond amount that must be maintained after the contract term shall be sufficient to cover all outstanding liabilities and will be determined by AHCCCS. The Contractor may not change the amount of the
performance bond without prior written approval from AHCCCS, Division of Health Care Management. Refer to ACOM Policy 306 for more details. 
 48.
ACCUMULATED FUND DEFICIT 
 The Contractor and its owners must review for accumulated fund deficits on a quarterly and annual basis. In the event the
Contractor has a fund deficit, the Contractor and its owners shall fund the deficit through capital contributions in a form acceptable to AHCCCS. The capital contributions must be for the period in which the deficit is reported and shall occur
within 30 days of the financial statement due to AHCCCS. AHCCCS at its sole discretion may impose a different timeframe other than the 30 days required in this paragraph. AHCCCS may, at its option, impose enrollment caps in any or all GSA’s as
a result of an accumulated deficit, even if unaudited. 
 49. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS 

The Contractor shall not, without the prior approval of AHCCCS, make any advances, distributions, loans, loan guarantees, or investments, to related parties or
affiliates including another fund or line of business within its organization. The Contractor shall not, without prior approval of AHCCCS, make loans or advances to providers in excess of $50,000. All requests for prior approval are to be submitted
to the AHCCCS, Division of Health Care Management, as specified in Attachment F3, Contractor Chart of Deliverables. Refer to ACOM Policy 418 for further information. 

50. FINANCIAL VIABILITY STANDARDS 
 The Contractor must
comply with the AHCCCS-established financial viability standards. On a quarterly basis, AHCCCS will review the following ratios with the purpose of monitoring the financial health of the Contractor: current ratio; equity per member; medical expense
ratio; and the administrative cost percentage. These same standards will be reviewed for the financial statements applicable to the Contractor’s Medicare line of business if the Contractor is certified by AHCCCS. 

Sanctions may be imposed if the Contractor does not meet these financial viability standards. AHCCCS will take into account the Contractor’s unique
programs for managing care and improving the health status of members when analyzing medical expense and administrative ratio results. However, if a critical combination of the financial viability standards is not met, or if the Contractor’s
experience differs significantly from other Contractors, additional monitoring, such as monthly reporting, may be required. 
 FINANCIAL VIABILITY
STANDARDS – Acute Care 
  

			
	Current Ratio	  	 Current assets divided by current liabilities. “Current assets” includes any long-term investments that can be converted to cash
within 24 hours without significant penalty (i.e., greater than 20%).
  
 Standard: At
least 1.00
  
 If current assets include a receivable from a parent company, the
parent company must have liquid assets that support the amount of the inter-company loan.



  
 Acute Care Contract 

10/01/2015 Renewal 
  

92 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


			
	 Equity per Member
	  	 Unrestricted equity, less on-balance sheet performance bond, divided by the number of members enrolled at the end of the period.

 

Standard: At least        $170 for Contractors with enrollment
< 100,000
 $115 for Contractors with enrollment of 100,000+

 
 Additional information regarding the Equity per Member requirement may be found in ACOM
Policy 306.

		
	 Medical Expense Ratio
	  	 Total medical expenses less TPL divided by the sum of total PPC and prospective capitation + Delivery Supplement + All Reconciliation
Settlements + Reinsurance less premium tax
  
 Standard: At least
85%

		
	 Administrative Cost Percentage
	  	 Total administrative expenses divided by the sum of total PPC and prospective capitation + Delivery Supplement + All Reconciliation
Settlements + Reinsurance less premium tax
  
 Standard: No greater than
10%

	
	 FINANCIAL VIABILITY STANDARD – Medicare Advantage Plan Certified by AHCCCS

		
	 Equity per Member
	  	 Unrestricted equity, less on-balance sheet performance bond, divided by the number of Medicare Advantage Plan dual eligible members
enrolled at the end of the period.
  
 Standard: At least $350


 Additional information regarding the Equity per Member requirement may be found in ACOM Policy 313. 

The Contractor shall comply with all financial reporting requirements contained in Attachment F3, Contractor Chart of Deliverables and the AHCCCS Financial
Reporting Guide for Acute Care Contractors, a copy of which may be found on the AHCCCS website. This reporting is required for both the Acute Care and Medicare lines of business, regardless of the licensing or certifying entity for the Medicare
Advantage Plan. If the Contractor is a Medicare Advantage Plan licensed through the Department of Insurance, quarterly reporting to AHCCCS is required for informational purposes only. The required reports are subject to change during the contract
term and are summarized in Attachment F3, Contractor Chart of Deliverables. See ACOM Policy 306 for more detail. 
 51. SEPARATE INCORPORATION 

Within 120 days of contract award, a non-governmental Contractor shall have established a separate corporation for the purposes of this contract, whose sole
activity is the performance of the requirements of this contract or other contracts with AHCCCS. 
 52. MERGER, ACQUISITION, REORGANIZATION, JOINT
VENTURE AND CHANGE IN OWNERSHIP 
 A merger, acquisition, reorganization, joint venture, and change in ownership of the Contractor shall require prior
approval of AHCCCS, as specified in ACOM Policy 317 and Attachment F3, Contractor Chart of Deliverables. The Contractor must submit notification and a detailed transition plan to AHCCCS 180 days prior to the effective date as outlined in ACOM Policy
317. The purpose of the plan review is to ensure uninterrupted services to 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

93 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 
members, evaluate the new entity’s ability to maintain and support the contract requirements, and to ensure that services to members are not diminished and that major components of the
organization and AHCCCS programs are not adversely affected by such merger, reorganization, joint venture or change in ownership. 
 A merger, acquisition,
reorganization, joint venture, and change in ownership of the Contractor may require a contract amendment. If the Contractor does not obtain prior approval, or AHCCCS determines that a merger, acquisition, reorganization, joint venture or change in
ownership is not in the best interest of the State, AHCCCS may terminate this contract pursuant to Section E, Contract Terms and Conditions, Paragraph 44, Temporary Management/Operation of a Contractor and Termination. AHCCCS may offer open
enrollment to the members assigned to the Contractor should a merger, acquisition, reorganization, joint venture, or change in ownership occur. AHCCCS will not permit one organization to own or manage more than one contract within the same program
in the same GSA. 
 53. COMPENSATION 
 The method of
compensation under this contract will be Prior Period Coverage (PPC) capitation, prospective capitation, delivery supplement, and reinsurance, as described and defined within this contract and appropriate laws, regulations or policies. 

Actuaries establish the capitation rates using practices established by the Actuarial Standards Board. AHCCCS provides the following data to its actuaries for
the purposes of rebasing and/or updating the capitation rates: 
  

	a.	Utilization and unit cost data derived from adjudicated encounters 

  

	b.	Both audited and unaudited financial statements reported by the Contractor 

  

	c.	Market basket inflation trends 

  

	d.	AHCCCS Fee-For-Service schedule pricing adjustments 

  

	e.	Programmatic or Medicaid covered service changes that affect reimbursement 

  

	f.	Other changes to medical practices or administrative requirements that affect reimbursement 

 AHCCCS adjusts
its rates to best match payment to risk. This further ensures the actuarial basis for the capitation rates. AHCCCS utilizes a national episodic/diagnostic risk adjustment model that will be applied to all prospective capitation rates for all risk
groups (excluding supplemental payments). AHCCCS’ actuaries shall determine if Adults > 106% FPL will or will not be included in risk adjustment. Additional risk factors that may be considered in capitation rate development include: 

 

	a.	Reinsurance (as described in Section D, Paragraph 57, Reinsurance) 

  

	b.	Age/Gender 

  

	c.	Medicare enrollment 

  

	d.	Delivery supplemental payment 

  

	e.	Geographic Service Area adjustments 

  

	f.	Risk sharing arrangements for specific populations 

  

	g.	Member specific statistics, e.g. member acuity, member choice, member diagnosis, etc. 

 The above information
is reviewed by AHCCCS’ actuaries in renewal years to determine if adjustments are necessary. A Contractor may cover services that are not covered under the State Plan or the Arizona Medicaid Section 1115 Demonstration Waiver Special Terms
and Conditions approved by CMS; however those services are not included in the data provided to actuaries for setting capitation rates [42 CFR 438.6(e)] (Section 1903(i) and 1903(i)(17) of the Social Security Act).xvii Graduate Medical Education payments (GME) are not included in the capitation rates but paid out separately consistent with the terms of Arizona’s State Plan.xviii Likewise, because AHCCCS does not delegate any of its responsibilities for administering Electronic Health Record (EHR) incentive payments to the Contractor, EHR payments are also
excluded from the capitation rates and are paid out separately by AHCCCS pursuant to Section 4201 of the HITECH Act, 42 USC 1396b(t), and 42 CFR 495.300 et seq.xix 

 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

94 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 In instances in which AHCCCS has specialty contracts or legislation/policy limits the allowable reimbursement
for certain services or pharmaceuticals, the amount to be used in the capitation rate setting process and reconciliations will be the lesser of the contracted/mandated amount or the Contractor paid amount. 

Prospective Capitation: The Contractor will be paid capitation for all prospective member months, including partial member months. This
capitation includes the cost of providing medically necessary covered services to members during the prospective period coverage. 
 Prior Period
Coverage (PPC) Capitation: Except for SOBRA Family Planning services, and KidsCare, the Contractor will be paid capitation for all PPC member months, including partial member months. This capitation includes the cost of providing medically
necessary covered services to members during prior period coverage. The PPC capitation rates will be set by AHCCCS and will be paid to the Contractor along with the prospective capitation described above. The Contractor will not receive PPC
capitation for newborns of members who are enrolled at the time of delivery. There is no PPC capitation for members enrolled with the Contractor who are initially found eligible for AHCCCS through Hospital Presumptive Eligibility. These members
will receive coverage of services during the PPC period through AHCCCS Fee-For-Service. 
 Reconciliation of Prospective Costs to
Reimbursement: AHCCCS will reconcile the Contractor’s prospective medical cost expenses to prospective net capitation paid to the Contractor. Refer to ACOM Policy 311 CYE 14 AND FORWARD for further details. This reconciliation will
limit the Contractor’s profits and losses as follows: 
  

																	
	 Profit
	  	MCO Share	 	 	State Share	 	 	Max MCO
Profit	 	 	Cumulative
MCO Profit	 
	 <= 3%
	  	 	100	% 	 	 	0	% 	 	 	3	% 	 	 	3	% 
	 > 3% and <= 6 %
	  	 	50	% 	 	 	50	% 	 	 	1.5	% 	 	 	4.5	% 
	 > 6%
	  	 	0	% 	 	 	100	% 	 	 	0	% 	 	 	4.5	% 

  

																	
	 Loss
	  	MCO Share	 	 	State Share	 	 	Max MCO
Loss	 	 	Cumulative
MCO Loss	 
	 <= 3%
	  	 	100	% 	 	 	0	% 	 	 	3	% 	 	 	3	% 
	 > 3%
	  	 	0	% 	 	 	100	% 	 	 	0	% 	 	 	3	% 

 Reconciliation of PPC Costs to Reimbursement: AHCCCS will reconcile the Contractor’s PPC medical cost
expenses to PPC capitation paid to the Contractor during the year. This reconciliation will limit the Contractor’s profits and losses to 2%. Any losses in excess of 2% will be reimbursed to the Contractor, and likewise, profits in excess of 2%
will be recouped. Refer to ACOM Policy 302 CYE 14 AND FORWARD for further details. 
 Reconciliation of Adult Group above 106% Federal Poverty Level
Costs to Reimbursement (Adults > 106%): AHCCCS will reconcile the Contractor’s Prospective and PPC medical cost expenses to Prospective and PPC capitation paid to the Contractor during the contract year for the Adults >
106%. This reconciliation will limit the Contractor’s profits and losses to 1%. Any losses in excess of 1% will be reimbursed to the Contractor, and likewise, profits in excess of 1% will be recouped. Refer to ACOM Policy 316 CYE14 AND FORWARD
for further details. 
 Reconciliation of Value-Based Purchasing Initiative: AHCCCS will settle the Contractor’s quality
contributions and quality distributions through a reconciliation. Quality distributions in excess of quality contributions will be paid to the Contractor. Quality contributions in excess of quality distributions will be recouped from the
Contractor. Value-Based Purchasing (VBP) payments made by the Contractor to providers will be incorporated in the reconciliation. Refer to ACOM Policy 315 CYE16 for further details. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

95 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Cost Settlement for Primary Care Payment Parity: The Patient Protection and Affordable Care Act
(ACA) requires that the Contractor make enhanced payments for primary care services delivered by, or under the supervision of, a physician with a specialty designation of family medicine, general internal medicine, or pediatric
medicine. [11/06/2012 final rule, 42 CFR 438.6(c)(5)(vi), 42 CFR 447.400(a)] The Contractor shall base enhanced primary care payments on the Medicare Part B fee schedule rate or, if greater, the payment rate that would be applicable in
2013 and 2014 using the CY 2009 Medicare physician fee schedule conversion factor. If no applicable rate is established by Medicare, the Contractor shall use the rate specified in a fee schedule established by CMS. [11/06/2012 final rule, 42
CFR 438.6(c)(5)(vi), 42 CFR 447.405] The Contractor shall make enhanced primary care payments for all Medicaid-covered Evaluation and Management (E&M) billing codes 99201 through 99499 and Current Procedural Terminology (CPT) vaccine
administration codes 90460, 90461, 90471, 90472, 90473, and 90474, or their successor codes. [11/06/2012 final rule, 42 CFR 438.6(c)(5)(vi), 42 CFR 447.405(c)] xx AHCCCS has developed an
enhanced fee schedule containing the qualifying codes using the 2009 Medicare conversion factor in compliance with the greater-of requirement. The enhanced payments apply only to services provided on and after January 1, 2013 by qualified
providers, who self-attest to AHCCCS as defined in the federal regulations. These reimbursement requirements for the enhanced payments apply to payments made for dates of service January 1, 2013 through December 31, 2014. 

The Contractor shall reprocess all qualifying claims for qualifying providers back to January 1, 2013 dates of service with no requirements that
providers re-submit claims or initiate any action. The Contractor shall not apply any discounts to the enhanced rates. 
 In the event that a provider
retroactively loses his/her qualification for enhanced payments, the Contractor shall identify impacted claims and automatically reprocess for the recoupment of enhanced payments. It is expected that this reprocessing will be conducted by the
Contractor without requirement of further action by the provider. 
 AHCCCS will make quarterly cost-settlement payments to the Contractor. The
cost-settlement payment is a separate payment arrangement from the capitation payment. (CMS Medicaid Managed Care Payment for PCP Services in 2013 and 2014: Technical Guide and Rate Setting Practices) Cost Settlement payments will be based upon
adjudicated/approved encounter data.xxi This data will provide the necessary documentation to AHCCCS, sufficient to enable AHCCCS and CMS to ensure that primary care enhanced payments were made to
network providers. [11/06/2012 final rule, 42 CFR 438.6(c)(5)(vi)(B)xxii] The Contractor will be required to refund payments to
AHCCCS for any reduced claim payments in the event that a provider is subsequently “decertified” for enhanced payments due to audit or other reasons. 

Refer to ACOM Policy 207 for further details. 
 Delivery
Supplement: When the Contractor has an enrolled woman who delivers during a prospective enrollment period, the Contractor will be entitled to a supplemental payment. Supplemental payments will not apply to women who deliver in a prior period
coverage time period, or State Only Transplant members. AHCCCS reserves the right at any time during the term of this contract to adjust the amount of this payment for women who deliver at home. See ACOM Policy 310. 

Health Insurer Fee: Section 9010 of the Patient Protection and Affordable Care Act (ACA) requires that the Contractor, if applicable, pay a
Health Insurer Assessment Fee (HIF) annually beginning in 2014 based on its respective market share of premium revenues from the preceding year. Subject to the receipt of documentation from the Contractor regarding the amount of the
Contractor’s liability for the HIF, AHCCCS shall make a capitation rate adjustment consistent with a methodology approved by CMS to approximate the cost associated with the HIF. The cost of the Assessment Fee will include both the Assessment
Fee itself and the corporate income tax liability the Contractor incurs related to the Assessment Fee. The Contractor must submit the items specified in Attachment F3, Contractor Chart of Deliverables to the DHCM Finance Manager. See ACOM Policy 320
with further details. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

96 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 State Only Transplants Option 1 and Option 2: The Contractor will only be paid capitation for
an administrative component for those member months the member is enrolled with the Contractor. For Option 1 members the Contractor will be paid the administrative component up to a 12-month continuous period of extended eligibility. For Option 2
members the administrative component will be paid for the period of time the transplant is scheduled or performed. All medically necessary covered services will be reimbursed 100% with no deductible through Reinsurance payments based on adjudicated
encounters. Delivery supplemental payments will not apply to women who deliver during the 12 month continuous period of extended eligibility specified as Option 1. 

54. PAYMENTS TO CONTRACTORS 
 Subject to the availability
of funds, AHCCCS shall make payments to the Contractor in accordance with the terms of this contract provided that the Contractor’s performance is in compliance with the terms and conditions of this contract. Payment must comply with
requirements of A.R.S. Title 36. AHCCCS reserves the option to make payments to the Contractor by wire or National Automated Clearing House Association (NACHA) transfer and will provide the Contractor at least 30 days’ notice prior to the
effective date of any such change. 
 Where payments are made by electronic funds transfer, AHCCCS shall not be liable for any error or delay in transfer or
indirect or consequential damages arising from the use of the electronic funds transfer process. Any charges or expenses imposed by the bank for transfers or related actions shall be borne by the Contractor. Except for adjustments made to correct
errors in payment, and as otherwise specified in this contract, any savings remaining to the Contractor as a result of favorable claims experience and efficiencies in service delivery at the end of the contract term may be kept by the Contractor.

 All funds received by the Contractor pursuant to this contract shall be separately accounted for in accordance with generally accepted accounting
principles. 
 Except for monies received from the collection of third-party liabilities, the only source of payment to the Contractor for the services
provided hereunder is from funds under the control of the AHCCCS. An error discovered by the State, in the amount of fees paid to the Contractor, with or without an audit, will be subject to adjustment or repayment by AHCCCS via a recoupment from
future payment(s) to the Contractor, or by making an additional payment to the Contractor. When the Contractor identifies an overpayment, AHCCCS must be notified and reimbursed within 30 days of identification. 

No payment due the Contractor by AHCCCS may be assigned or pledged by the Contractor. This section shall not prohibit AHCCCS at its sole option from making
payment to a fiscal agent hired by the Contractor. 
 55. CAPITATION ADJUSTMENTS 

Except for changes made specifically in accordance with this contract, the rates set forth in Section B shall not be subject to re-negotiation during the
contract period. AHCCCS may, at its option, review capitation rates to determine if a capitation adjustment is needed for reasons including, but not limited to, the following: 
  


	 	•	 	Program changes 

  

	 	•	 	Legislative requirements 

  

	 	•	 	Changes in trend assumptions 

  

	 	•	 	Updated encounter experience 

  

	 	•	 	Actuarial assumptions 

 If a capitation rate adjustment is determined necessary, the adjustment and assumptions
may be discussed with the Contractor prior to modifying capitation rates. The Contractor may request a review of a program change if it believes the program change was not equitable; AHCCCS will not unreasonably withhold such a review. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

97 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 The Contractor is responsible for notifying AHCCCS of program and/or expenditure changes initiated by the
Contractor during the contract period that may result in material changes to the current or future capitation rates. 
 Contractor Default: If
the Contractor is in any manner in default in the performance of any obligation under this contract, AHCCCS may, at its option and in addition to other available remedies, adjust the amount of payment until there is satisfactory resolution of the
default. 
 Change in Member Status: The Contractor shall reimburse AHCCCS and/or AHCCCS may deduct from future monthly capitation for any
portion of a month during which the Contractor was not at risk due to, for example: 
  

	a.	Death of a member 

  

	b.	Inmate of a public institution 

  

	c.	Duplicate capitation to the same Contractor 

  

	d.	Adjustment based on change in member’s contract type 

  

	e.	Voluntary withdrawal 

 Upon becoming aware that a member may be an inmate of a public institution, the
Contractor must notify AHCCCS for an eligibility determination. Notifications must be sent via email to one of the following two email addresses as applicable: 

For children under age 18: DMSJUVENILEIncarceration@azahcccs.gov 

For adults age 18 and older: DMSADULTIncarceration@azahcccs.gov 

Notifications must include: 
  

	a.	AHCCCS ID 

  

	b.	Name 

  

	c.	Date of Birth (DOB) 

  

	d.	When incarcerated 

  

	e.	Where incarcerated 

 The Contractor does not need to report members incarcerated with the Arizona
Department of Corrections. 
 Several counties are submitting daily files of all inmates entering their jail and all inmates released. AHCCCS will match
these files against the database of active AHCCCS members. AHCCCS members who become incarcerated will be disenrolled from their Contractor and placed in a “no-pay” status for the duration of their incarceration. The Contractor will see
the “IE” code for ineligible associated with the disenrollment. Upon release from jail, the member will be re-enrolled with their previous Contractor. A member is eligible for covered services until the effective date of the member’s
“no-pay” status. 
 If a member is enrolled twice with the same Contractor, recoupment will be made as soon as the double capitation is
identified. AHCCCS reserves the right to modify its policy on capitation recoupments at any time during the term of this contract. 
 56. MEMBER BILLING
AND LIABILITY FOR PAYMENT 
 AHCCCS registered providers may charge AHCCCS members for services which are excluded from AHCCCS coverage or which are
provided in excess of AHCCCS limits according to the guidelines set forth in A.A.C. R9-22-702. 
 The Contractor must ensure that members are not held
liable for: 
  

	a.	The Contractor’s or any subcontractor’s debts in the event of Contractor’s or the subcontractor’s insolvency [42 CFR 438.106(a)]; 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

98 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	b.	Covered services provided to the member except as permitted under A.A.C. R9-22-702, [42 CFR 438.106(b)(1)]; or, 

  

	c.	Payments to the Contractor or any subcontractors for covered services furnished under a contract, referral or other arrangement, to the extent that those payments are in excess of the amount the member would owe if the
Contractor or any subcontractor provided the services directly [42 CFR 438.106(b)(2); 42 CFR 438.106(c); 42 CFR 438.6(l); 42 CFR 438.230]. 


57. REINSURANCE 
 Reinsurance is a stop-loss program
provided by AHCCCS to the Contractor for the partial reimbursement of covered medical services incurred for a member beyond an annual deductible level. AHCCCS is self-insured for the reinsurance program which is characterized by an initial
deductible level and a subsequent coinsurance percentage. The coinsurance percentage is the rate at which AHCCCS will reimburse the Contractor for covered services incurred above the deductible. The deductible is the responsibility of the
Contractor. Deductible levels are subject to change by AHCCCS during the term of this contract. Any change would have a corresponding impact on capitation rates. The reinsurance contract year is the year beginning on October 1 and ending on
September 30. Refer to the AHCCCS Reinsurance Policy Manual for further details on the Reinsurance Program. 
 The table below represents deductible
and coinsurance levels. See specific case types below for coverage details. 
  

					
	 Reinsurance Case Type
	  	Deductible	  	Coinsurance
	 Regular Reinsurance including reinsurance for dual eligible members with GMH/SA needs (See specific details below)
	  	$25,000	  	75%
	 Catastrophic Reinsurance
	  	NA	  	85%
	 Transplant and Other Case Types
	  	See specific
paragraphs below	  	See specific
paragraphs below

 Annual deductible levels apply to all members except for State Only Transplant. These deductible levels are subject to change
by AHCCCS during the term of this contract. Any change in deductible levels will have a corresponding impact on capitation rates. 
 PPC expenses are not
covered for any members under the reinsurance program unless they qualify under transplant reinsurance. 
 Reinsurance Case Types 

For all reinsurance case types, in the instances in which AHCCCS has specialty contracts or legislation/policy limits the allowable reimbursement for certain
services or pharmaceuticals the amount to be used in the computation of reinsurance will be the lesser of the contracted/mandated amount or the Contractor paid amount. 

Regular Reinsurance: Regular reinsurance covers partial reimbursement of covered inpatient facility medical services. This coverage applies to
prospective enrollment periods. In certain situations as outlined in the AHCCCS Reinsurance Policy Manual, per diem rates paid for nursing facility services provided within 30 days of an acute hospital stay, including room and board, provided in
lieu of hospitalization for up to 90 days in any contract year shall be eligible for reinsurance coverage. Same-day admit-and-discharge services do not 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

99 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 
qualify for reinsurance. Regular reinsurance coverage for dual eligible members with GMH/SA needs covers behavioral health services provided at inpatient acute facilities only; services provided
by any other inpatient provider type, including but not limited to residential treatment centers and subacute facilities, are not eligible for reinsurance reimbursement. See the Reinsurance Policy Manual for additional details. 

Catastrophic Reinsurance: The Catastrophic Reinsurance program encompasses members receiving certain biotech drugs and those members diagnosed
with hemophilia, von Willebrand’s Disease or Gaucher’s Disease, as follows: 
 Biotech Drugs: Catastrophic reinsurance is
available to cover the cost of certain biotech drugs when medically necessary. The biotech drugs covered under reinsurance may be reviewed by AHCCCS at the start of each contract year. Refer to the AHCCCS Reinsurance Policy Manual for a complete
list of the approved biotech drugs. When a generic equivalent of a biotech drug is available, AHCCCS will reimburse at the lesser of the biotech drug or its generic equivalent for reinsurance purposes, unless the generic equivalent is
contra-indicated for a specific member. 
 Hemophilia: Catastrophic reinsurance coverage is available for all members diagnosed with
Hemophilia. 
 Von Willebrand’s Disease: Catastrophic reinsurance coverage is available for all members diagnosed with von
Willebrand’s Disease who are non-DDAVP responders and dependent on Plasma Factor VIII. 
 Gaucher’s Disease: Catastrophic
reinsurance is available for members diagnosed with Gaucher’s Disease classified as Type I and are dependent on enzyme replacement therapy. 
 For
additional detail and restrictions refer to the AHCCCS Reinsurance Policy Manual and the AMPM. There are no deductibles for catastrophic reinsurance cases. For member’s receiving biotech drugs, AHCCCS will reimburse at 85% of the cost of the
drug only. For those members diagnosed with hemophilia, von Willebrand’s Disease and Gaucher’s Disease, all medically necessary covered services provided during the contract year shall be eligible for reimbursement at 85% of the AHCCCS
allowed amount or the Contractor’s paid amount, whichever is lower, depending on the subcap/CN1 code indicated on the encounter. 
 AHCCCS holds a
specialty contract for anti-hemophilic agents and related services for hemophilia. The Contractor may access anti-hemophilic agents and related pharmaceutical services for hemophilia or von Willebrand’s under the terms and conditions of the
specialty contract for members enrolled in their plans. In that instance, the Contractor is the authorizing payor. As such, the Contractor will provide prior authorization, care coordination, and reimbursement for all components covered under the
contract for their members. A Contractor utilizing the contract will comply with the terms and conditions of the contract. A Contractor may use the AHCCCS contract or contract with a provider of their choice. Reinsurance coverage for anti-hemophilic
blood factors will be limited to 85% of the AHCCCS contracted amount or the Contractor’s paid amount, whichever is lower. 
 The Contractor must notify
AHCCCS, DHCM Medical Management, of cases identified for catastrophic reinsurance coverage, as specified in Attachment F3, Contractor Chart of Deliverables. Catastrophic reinsurance will be paid for a maximum 30-day retroactive period from the date
of notification to AHCCCS. 
 All catastrophic claims are subject to medical review by AHCCCS. 

Transplant Reinsurance: This program covers members who are eligible to receive covered major organ and tissue transplantation. Refer to the
AMPM and the AHCCCS Reinsurance Policy Manual for covered services for organ and tissue transplants. Reinsurance coverage for transplants received at an AHCCCS contracted facility is paid at the lesser of 85% of the AHCCCS contract amount for the
transplantation services rendered 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

100 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 
or 85% of the Contractor’s paid amount. A new component for follow-up care post-transplant has been added to the transplant contracts. Reinsurance for these components will follow the
regular reinsurance reimbursement, including a deductible requirement. Reinsurance coverage for transplants received at a non-AHCCCS contracted facility is paid the lesser of 85% of the lowest AHCCCS contracted rate, for the same organ or tissue, or
the Contractor paid amount. The new follow-up care component will receive reinsurance coverage in accordance with regular reinsurance reimbursement, including a deductible requirement. The AHCCCS contracted transplantation rates may be found on the
AHCCCS website. The Contractor must notify AHCCCS, DHCM Medical Management when a member is referred to a transplant facility for evaluation for an AHCCCS-covered organ transplant. In order to qualify for reinsurance benefits, the notification must
be received by AHCCCS Medical Management within 30 days of referral to the transplant facility for evaluation. 
 If a Contractor intends to use an out of
State transplant facility for a covered transplant and AHCCCS already holds an in State contract for that transplant type, the Contractor must obtain prior approval from the AHCCCS Medical Director. If no prior approval is obtained, and the
Contractor incurs costs at the out of State facility, those costs will not be eligible for either transplant or regular reinsurance. 
 Option 1 and
Option 2 Transplant Services: Reinsurance coverage for State Only Option 1 and Option 2 members (as described in Section D, Paragraph 2, Eligibility Categories) for transplants received at an AHCCCS contracted facility is paid at the lesser
of 100% of the AHCCCS contract amount for the transplantation services rendered, or the Contractor paid amount, less the transplant share of cost. For transplants received at a facility not contracted with AHCCCS, payment is made at the lesser of
100% of the lowest AHCCCS contracted amount for the transplantation services rendered, or the Contractor paid amount, less the transplant share of cost. All Option 1 and Option 2 transplants are subject to the terms regarding out of State
transplants set forth above and in the AHCCCS Reinsurance Policy Manual. The AHCCCS contracted transplantation rates may be found on the AHCCCS website. When a member is referred to a transplant facility for evaluation for an AHCCCS-covered organ
transplant, the Contractor shall notify AHCCCS, DHCM Medical Management as specified in the AMPM Chapter 300. 
 Option 1 Non-transplant
Reinsurance: All medically necessary covered services provided to Option 1 members, unrelated to the transplant, shall be eligible for reimbursement, with no deductible, at 100% of the Contractor’s paid amount based on
adjudicated encounters. 
 Other Reinsurance: For all reinsurance case types other than transplants, the Contractor will be reimbursed 100%
for all medically necessary covered expenses provided in a contract year, after the Contractor paid amount in the reinsurance case reaches $650,000. It is the responsibility of the Contractor to notify AHCCCS, DHCM, Reinsurance Supervisor, once a
reinsurance case reaches $650,000. Failure to notify AHCCCS or failure to adjudicate encounters appropriately within 15 months from the end date or service will disqualify the related encounters for 100% reimbursement consideration. 

Encounter Submission and Payments for Reinsurance 

Encounter Submission: All reinsurance associated encounters, except as provided below for “Disputed Matters,” must reach a clean claim
status within 15 months from the end date of service, or date of eligibility posting, whichever is later. 
 Encounters for claims which cross over contract
years will not be eligible for reinsurance. 
 AHCCCS will not pay reinsurance on encounters for interim claims. The final claim submitted by a hospital
associated with the full length of the patient stay will be eligible for reinsurance consideration as long as the days of the hospital stay do not cross contract years. 

AHCCCS will not pay reinsurance on encounters containing any PPC for regular, catastrophic and other reinsurance case types. Splitting claims for the purpose
of separating PPC from prospective enrollment is not permitted. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

101 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Disputed Matters: For encounters which are the subject of a member appeal, provider claim
dispute, or other legal action, including an informal resolution originating from a request for a formal claim dispute or member appeal, the Contractor has the greater of: 1) 90 days from the date of the final decision in that proceeding/action or
2) 15 months from the end date of service/date of eligibility posting to file the reinsurance claim AND for the reinsurance claim to reach clean claim status. Therefore, reinsurance claims for disputed matters will be considered timely if the
Contractor files such claims in clean claim status no later than 90 days from the date of the final decision in that proceeding/action even though the 15 month deadline has expired. 

Failure to submit encounters in clean claim status within the applicable timeframes specified above will result in the denial of reinsurance. The association
of an encounter to a reinsurance case does not automatically qualify the encounter for reinsurance reimbursement. 
 The Contractor must void encounters for
any claims that are recouped in full. For recoupments that result in a reduced claim value or any adjustments that result in an increased claim value, replacement encounters must be submitted. See the AHCCCS Reinsurance Policy Manual for further
details. The Contractor should refer to Section D, Paragraph 65, Encounter Data Reporting, for additional encounter reporting requirements. 

Payment of Regular and Catastrophic Reinsurance Cases: AHCCCS will reimburse a Contractor for costs incurred in excess of the applicable
deductible level, subject to coinsurance percentages and Medicare/TPL payment, less any applicable quick pay discounts, slow payment penalties and interest. Amounts in excess of the deductible level shall be paid based upon costs paid by the
Contractor, minus the coinsurance and Medicare/TPL payment, unless the costs are paid under a subcapitated arrangement. In subcapitated arrangements, AHCCCS shall base reimbursement of reinsurance encounters on the lower of the AHCCCS allowed amount
or the reported health plan paid amount, minus the coinsurance and Medicare/TPL payment and applicable quick pay discounts, slow payment penalties and interest. 

When a member with an annual enrollment choice changes Contractors within a contract year, for reinsurance purposes, costs incurred for that member do not
follow the member to the receiving Contractor. Encounters from the Contractor the member is leaving (for dates of service within the current contract year) will not be applied toward the receiving Contractor’s deductible level. For further
details regarding this policy and other reinsurance policies refer to the AHCCCS Reinsurance Policy Manual. 
 Payment of Transplant
Reinsurance Cases: Reinsurance benefits are based upon the lower of the AHCCCS contract amount or the Contractor’s paid amount, subject to coinsurance percentages. The Contractor is required to submit all supporting encounters
for transplant services. Reinsurance payments are linked to transplant encounter submissions. In order to receive reinsurance payment for transplant stages, billed amounts and health plan paid amounts for adjudicated encounters must agree with
related claims and/or invoices. Timeliness for each stage payment will be calculated based on the latest adjudication date for the complete set of encounters related to the stage. Refer to the AHCCCS Reinsurance Policy Manual for the appropriate
billing of transplant services. 
 Reinsurance Audits 

AHCCCS may, at a later date, perform medical audits on reinsurance cases. Terms of the audit process will be disclosed prior to implementation of the audits
providing the Contractor with appropriate advance notice. 
 58. COORDINATION OF BENEFITS AND THIRD PARTY LIABILITY 

AHCCCS is the payor of last resort unless specifically prohibited by applicable State or Federal law. This means AHCCCS shall be used as a source of payment
for covered services only after all other sources of payment have been exhausted. The Contractor shall take reasonable measures to identify potentially legally liable third party sources. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

102 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 If the Contractor discovers the probable existence of a liable third party that is not known to AHCCCS, or
identifies any change in coverage, the Contractor must report the information within 10 days of discovery, as specified in Attachment F3, Contractor Chart of Deliverables. Failure to report these cases may result in one of the remedies specified in
Section D, Paragraph 72, Sanctions. AHCCCS will provide the Contractor with a file of all other coverage information, for the purpose of updating the Contractor’s files, as described in the AHCCCS Technical Interface Guidelines. 

The Contractor shall coordinate benefits in accordance with 42 CFR 433.135 et seq., A.R.S. §36-2903, and A.A.C. R9-22-1001 et seq., so that costs for
services otherwise payable by the Contractor are cost avoided or recovered from a liable third party [42 CFR 434.6(a)(9)]. The term “State” shall be interpreted to mean “Contractor” for purposes of complying with the Federal
regulations referenced above. The Contractor may require subcontractors to be responsible for coordination of benefits for services provided pursuant to this contract. The two methods used for coordination of benefits are cost avoidance and
post-payment recovery. The Contractor shall use these methods as described in A.A.C. R9-22-1001 et seq., Federal and State law, and AHCCCS Policy. 

Cost Avoidance 
 The Contractor shall take reasonable
measures to determine all legally liable parties. This refers to any individual, entity or program that is or may be liable to pay all or part of the expenditures for covered services. The Contractor shall cost avoid a claim if it has established
the probable existence of a liable party at the time the claim is filed. For purposes of cost avoidance, establishing liability takes place when the Contractor receives confirmation that another party is, by statute, contract, or agreement, legally
responsible for the payment of a claim for a healthcare item or service delivered to a member. If the probable existence of a party’s liability cannot be established, the Contractor must adjudicate the claim. The Contractor must then utilize
post-payment recovery which is described in further detail below. If AHCCCS determines that the Contractor is not actively engaged in cost avoidance activities, the Contractor shall be subject to sanctions. 

If a third party insurer other than Medicare requires the member to pay any copayment, coinsurance or deductible, the Contractor is responsible for making
these payments in accordance with ACOM Policy 434. 
 Claims for inpatient stay for labor, delivery and postpartum care, including professional fees when
there is no global OB package, must be cost avoided. [42 CFR 433.139] 
 Timely Filing: The Contractor shall not deny a claim for timeliness
if the untimely claim submission results from a provider’s efforts to determine the extent of liability. 
 Members Covered by both Medicare and
Medicaid (Duals): See Section D, Paragraph 60, Medicare Services and Cost Sharing. 
 Members with a CRS Condition: Members under 21
years of age who are determined to have a qualifying CRS condition will be enrolled with the CRS Contractor. Members with private insurance or Medicare may use their private insurance or Medicare provider networks to obtain services including those
for the CRS condition. The CRS Contractor is responsible for payment for services provided to its enrolled members according to CRS coverage type. See ACOM Policy 426 for CRS Contractor coverage responsibilities and coordination of benefits. If the
member has Medicare coverage, ACOM Policy 201 shall apply.  
 Post-Payment Recoveries 

Post-payment recovery is necessary in cases where the Contractor has not established the probable existence of a liable third party at the time services were
rendered or paid for, was unable to cost-avoid, or post-payment recovery is required. In these instances, the Contractor must adjudicate the claim and then utilize post-payment recovery processes which include: Pay and Chase, Retroactive Recoveries
Involving Commercial Insurance Payor Sources, and other third party liability recoveries. Refer to ACOM Policy 434 for further guidance. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

103 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Pay and Chase: The Contractor shall pay the full amount of the claim according to the AHCCCS
Capped-Fee-For-Service Schedule or the contracted rate and then seek reimbursement from any third party if the claim is for the following: 
  

	a.	Prenatal care for pregnant women, including services which are part of a global OB Package; 

  

	b.	Preventive pediatric services, including Early and Periodic Screening Diagnosis and Treatment (EPSDT) and administration of vaccines to children under the Vaccines for Children (VFC) program; 


 

	c.	Services covered by third party liability that are derived from an absent parent whose obligation to pay support is being enforced by the Division of Child Support Enforcement; or 


 

	d.	Services for which the Contractor fails to establish the existence of a liable third party at the time the claim is filed. 


Retroactive Recoveries Involving Commercial Insurance Payor Sources: For a period of two years from the date of service, the Contractor shall
engage in retroactive third party recovery efforts for claims paid to determine if there are commercial insurance payor sources that were not known at the time of payment. In the event a commercial insurance payor source is identified, the
Contractor must seek recovery from the commercial insurance. The Contractor is prohibited from recouping related payments from providers, requiring providers to take action, or requiring the involvement of providers in any way. 

The Contractor has two years from the date of service to recover payments for a particular claim, or to identify claims having a reasonable expectation of
recovery. A reasonable expectation of recovery is established when the Contractor has affirmatively identified a commercial insurance payor source and has begun the process of recovering payment. If AHCCCS determines that a Contractor is tagging
claims that do not meet these requirements, AHCCCS may impose sanctions. After two years from the date of service, AHCCCS will direct recovery efforts for any claims not tagged by the Contractor. 

AHCCCS will direct recovery efforts for retroactive recovery of claims not previously identified by the Contractor as having a reasonable expectation of
recovery. Any recoveries obtained by AHCCCS through its recovery efforts will be retained exclusively by AHCCCS and will not be shared with the Contractor. 

The timeframe for submission of claims for recovery is limited to three years from the date of service consistent with A.R.S. §36-2923 and the Deficit
Reduction Act of 2005 (Public Law 109-171). 
 See ACOM Policy 434 for details regarding encounter adjustments as a result of retroactive recoveries and the
processes for identifying claims that have a reasonable expectation of recovery. 
 Other Third Party Liability Recoveries: The Contractor
shall identify the existence of potentially liable parties using a variety of methods, including referrals, and data mining through the use of trauma code edits, utilizing the codes provided by AHCCCS. The Contractor shall not pursue recovery in the
following circumstances, unless the case has been referred to the Contractor by AHCCCS or AHCCCS’ authorized representative: 
  

	 	•	 	Motor Vehicle Cases 

  

	 	•	 	Other Casualty Cases 

  

	 	•	 	Tort feasors 

  

	 	•	 	Restitution Recoveries 

  

	 	•	 	Worker’s Compensation Cases 

 Upon identification of a potentially liable third party for any of the above
situations, the Contractor shall, within 10 business days, report the potentially liable third party to AHCCCS’ TPL Contractor for determination of a mass tort or total plan case. Failure to report these cases may result in one of the remedies
specified in Section D, Paragraph 72, Sanctions. A mass tort case is a case where multiple plaintiffs or a class of plaintiffs have filed a lawsuit against the same tort feasor(s) to recover damages arising from the same or similar set of
circumstances (e.g. class action lawsuits) regardless of whether any reinsurance or Fee-For-

  
 Acute Care Contract 

10/01/2015 Renewal 
  

104 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 
Service payments are involved. A total plan case is a case where payments for services rendered to the member are exclusively the responsibility of the Contractor; no reinsurance or
Fee-For-Service payments are involved. By contrast, a “joint” case is one where Fee-For-Service payments and/or reinsurance payments are involved. The Contractor shall cooperate with AHCCCS’ authorized representative in all collection
efforts. 
 Total Plan Cases: In “total plan” cases, the Contractor is responsible for performing all research, investigation, the
mandatory filing of initial liens on cases that exceed $250, lien amendments, lien releases, and payment of other related costs in accordance with A.R.S. §36-2915 and A.R.S. §36-2916. The Contractor shall use the AHCCCS-approved casualty
recovery correspondence when filing liens and when corresponding to others in regard to casualty recovery. The Contractor may retain up to 100% of its recovery collections if all of the following conditions exist: 

 

	a.	Total collections received do not exceed the total amount of the Contractor’s financial liability for the member; 

  

	b.	There are no payments made by AHCCCS related to Fee-For-Service, reinsurance or administrative costs (i.e., lien filing , etc.); and, 


 

	c.	Such recovery is not prohibited by State or Federal law. 

 Prior to negotiating a settlement on a total plan
case, the Contractor shall notify AHCCCS or AHCCCS’ authorized TPL Contractor to ensure that there is no reinsurance or Fee-For-Service payment that has been made by AHCCCS. Failure to report these cases prior to negotiating a settlement amount
may result in one of the remedies specified in Section D, Paragraph 72, Sanctions. 
 The Contractor shall report settlement information to AHCCCS,
utilizing the AHCCCS-approved casualty recovery Settlement Notification Form, within 10 business days from the settlement date or in an AHCCCS-approved monthly file, as specified in Attachment F3, Contractor Chart of Deliverables. Failure to report
these cases may result in one of the remedies specified in Section D, Paragraph 72, Sanctions. 
 Joint and Mass Tort Cases: AHCCCS’ authorized
representative is responsible for performing all research, investigation and payment of lien-related costs, subsequent to the referral of any and all relevant case information to AHCCCS’ authorized representative by the Contractor. In joint and
mass tort cases, AHCCCS’ authorized representative is also responsible for negotiating and acting in the best interest of all parties to obtain a reasonable settlement and may compromise a settlement in order to maximize overall reimbursement,
net of legal and other costs. The Contractor will be responsible for their prorated share of the contingency fee. The Contractor’s share of the contingency fee will be deducted from the settlement proceeds prior to AHCCCS remitting the
settlement to the Contractor. 
 Other Reporting Requirements 

All TPL reporting requirements are subject to validation through periodic audits and/or operational reviews which may include Contractor submission of an
electronic extract of the casualty cases, including open and closed cases. Data elements may include, but are not limited to: the member’s first and last name; AHCCCS ID; date of incident; claimed amount; paid/recovered amount; and case status.
The AHCCCS TPL Section shall provide the format and reporting schedule for this information to the Contractor. 
 Title XXI (KidsCare) and
BCCTP: Eligibility for KidsCare and BCCTP benefits require that the applicant/member not be enrolled with any other creditable health insurance plan. If the Contractor becomes aware of any such coverage, the Contractor shall notify AHCCCS
immediately. AHCCCS will determine if the other insurance meets the creditable coverage definition in A.R.S. §36-2982(G). 
 Cost
Avoidance/Recovery Report: The Contractor shall submit quarterly reports regarding cost avoidance/recovery activities, as specified in Attachment F3, Contractor Chart of Deliverables. The report shall be submitted in a format as specified in
the AHCCCS Program Integrity Reporting Guide. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

105 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Contract Termination: Upon termination of this contract, the Contractor will complete the
existing third party liability cases or make any necessary arrangements to transfer the cases to AHCCCS’ authorized TPL representative. 
 59.
COPAYMENTS 
 The Contractor is required to comply with A.A.C. R9-22-711, ACOM Policy 431 and other directives by AHCCCS. Those populations exempt from
copayments or subject to nominal (optional) copayments may not be denied services due to the inability to pay the copayment [42 CFR 438.108]. However, for those populations subject to mandatory copayments services may be denied for the inability to
pay the copayment. 
 60. MEDICARE SERVICES AND COST SHARING 

The Contractor must pay most Medicare coinsurance and/or deductibles for covered services provided to dual members. However, there are different cost-sharing
responsibilities that apply to dual members based on a variety of factors. The Contractor must limit their cost sharing responsibility according to A.A.C. R9-29-301 and A.A.C. R9-29-302 and as further outlined in ACOM Policy 201. Refer to Section D,
Paragraph 10, Scope of Services, for information regarding prescription medication for Medicare Part D. 
 Dual members shall have choice of all providers
in the network and shall not be restricted to those that accept Medicare. 
 When a dual member is in a medical institution and that stay is funded by
Medicaid for a full calendar month, the dual member is not required to pay copayments for their Medicare covered prescription medications for the remainder of the calendar year. To ensure appropriate information is communicated for these members to
CMS, the Contractor must notify AHCCCS pursuant to ACOM Policy 201. 
 61. MARKETING 

The Contractor shall comply with all Federal and State provisions regarding marketing including ACOM Policy 101 [42 CFR 438.104]. The Contractor shall submit
all proposed marketing materials, activities, and participation in events that will involve the general public to the AHCCCS Marketing Committee as specified in Attachment F3, Contractor Chart of Deliverables and as outlined in ACOM Policy 101. All
marketing materials that have been approved by the Marketing Committee must be resubmitted every two years for re-approval. 
 62. CORPORATE COMPLIANCE

 Corporate Compliance Program 
 The Contractor
shall be in compliance with 42 CFR 438.608. The Contractor must have a mandatory Corporate Compliance Program, supported by other administrative procedures including a Corporate Compliance Plan that is designed to guard against fraud, waste, and
abuse. The Contractor shall have written criteria for selecting a Compliance Officer and the job description clearly outlining the responsibilities and authority of the position. The Contractor’s written Corporate Compliance Plan must adhere to
Contract and ACOM Policy 103 and must be submitted annually to AHCCCS-OIG as specified in Attachment F3, Contractor Chart of Deliverables. 
 The compliance
program shall be designed to both prevent and detect fraud, waste, and abuse. The compliance program must include: 
  

	1.	Written policies, procedures, and standards of conduct that articulates the organization’s commitment to and processes for complying with all applicable Federal and State rules, regulations, guidelines, and
standards. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

106 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	2.	The Compliance Officer must be an onsite management official who reports directly to the Contractor’s top management. Any exceptions must be approved by AHCCCS. 


 

	3.	Effective lines of communication between the compliance officer and the Contractor’s employees. 

  

	4.	Enforcement of standards through well-publicized disciplinary guidelines. 

  

	5.	Provision for internal monitoring and auditing, as well as provisions for external monitoring and auditing of subcontractors. The Contractor shall provide the external auditing schedule and executive summary of all
audits to AHCCCS-OIG as specified in Attachment F3, Contractor Chart of Deliverables. 

  

	6.	Provision for prompt response to problems detected. 

  

	7.	The written designation of a Compliance Committee who is accountable to the Contractor’s top management. The Compliance Committee which shall be made up of, at a minimum, the Compliance Officer, a budgetary
official and other executive officials with the authority to commit resources. The Compliance Committee will assist the Compliance Officer in monitoring, reviewing and assessing the effectiveness of the compliance program and timeliness of
reporting. 

  

	8.	Pursuant to the Deficit Reduction Act of 2005 (DRA), Contractors, as a condition for receiving payments shall establish written policies for employees detailing: 


 

	 	a.	The Federal False Claims Act provisions; 

  

	 	b.	The administrative remedies for false claims and statements; 

  

	 	c.	Any State laws relating to civil or criminal penalties for false claims and statements; and 

  

	 	d.	The whistleblower protections under such laws. 

  

	9.	The Contractor must require, through documented policies and subsequent contract amendments, that subcontractors and providers train their staff on the following aspects of the Federal False Claims Act provisions:


  

	 	a.	The administrative remedies for false claims and statements; 

  

	 	b.	Any State laws relating to civil or criminal penalties for false claims and statements; and 

  

	 	c.	The whistleblower protections under such laws. 

  

	10.	The Contractor must establish a process for training existing staff and new hires on the compliance program and on the items in number 9 above. All training must be conducted in such a manner that can be verified by
AHCCCS. 

  

	11.	The Contractor must notify AHCCCS, DHCM Data Analysis and Research, as specified in Attachment F3, Contractor Chart of Deliverables of any CMS compliance issues related to HIPAA transaction and code set complaints or
sanctions. 

 Fraud Waste, and Abuse: In accordance with A.R.S. §36-2918.01, §36-2932, §36-2905.04 and ACOM
Policy 103, the Contractor, its subcontractors and providers are required to immediately notify the AHCCCS Office of Inspector General (AHCCCS-OIG) regarding all allegations of fraud, waste or abuse involving the AHCCCS Program. The Contractor shall
not conduct any investigation or review of the allegations of fraud, waste, or abuse involving the AHCCCS Program. Notification to AHCCCS-OIG shall be in accordance with ACOM Policy 103 and as specified in Attachment F3, Contractor Chart of
Deliverables. The Contractor must also report to AHCCCS, as specified in Attachment F3, Contractor Chart of Deliverables, any credentialing denials including, but not limited to those which are the result of licensure issues, quality of care
concerns, excluded providers, and which are due to alleged fraud, waste or abuse. In accordance with 42 CFR 455.14, AHCCCS-OIG will then conduct a preliminary investigation to determine if there is sufficient basis to warrant a full investigation.
[42 CFR 455.17][42 CFR 455.1(a)(1)]. As stated in A.R.S. §13-2310, incorporated herein by reference, any person who knowingly obtains any benefit by means of false or fraudulent pretenses, representations, promises, or material omissions is
guilty of a Class 2 felony. 
 The Contractor agrees to permit and cooperate with any onsite review. A review by the AHCCCS-OIG may be conducted without
notice and for the purpose of ensuring program compliance. The Contractor also agrees to respond to electronic, telephonic or written requests for information within the timeframe specified by AHCCCS. The Contractor agrees to provide documents,
including original documents, to representatives of the AHCCCS-OIG upon request and at no cost. The AHCCCS-OIG shall allow a reasonable time for the Contractor to copy the requested documents, not to exceed 20 business days from the date of the
AHCCCS-OIG request. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

107 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Once the Contractor has referred a case of alleged fraud, waste, or abuse to AHCCCS, the Contractor shall
take no action to recoup or otherwise offset any suspected overpayments. AHCCCS-OIG will notify the Contractor when the investigation concludes. If it is determined by AHCCCS-OIG to not be a fraud, waste, or abuse case, the Contractor shall adhere
to the applicable AHCCCS policy manuals for disposition. 
 In addition, the Contractor must furnish to AHCCCS or CMS within 35 days of receiving a request,
full and complete information, pertaining to business transactions [42 CFR 455.105]: 
  

	 	•	 	The ownership of any subcontractor with whom the Contractor has had business transactions totaling more than $25,000 during the 12-month period ending on the date of request; and 


 

	 	•	 	Any significant business transactions between the Contractor, any subcontractor, and wholly owned supplier, or between the Contractor and any subcontractor during the five year period ending on the date of the request.


 Disclosure of Ownership and Control [42 CFR 455.100 through 106](SMDL09-001)(Sections 1124(a)(2)(A) and 1903(m)(2)(A)(viii)
of the Social Security Act):xxiii 
 The Contractor must obtain the following information regarding
ownership and control [42 CFR 455.106]:xxiv 
  

	1.	The Name, Address, Date of Birth and Social Security Numbers of any individual with an ownership or control interest in the Contractor, including those individuals who have direct, indirect, or combined
direct/indirect ownership interest of 5% or more of the Contractor’s equity, owns 5% or more of any mortgage, deed of trust, note, or other obligation secured by the Contractor if that interest equals at least 5% of the value of the
Contractor’s assets, is an officer or director of a Contractor organized as a corporation, or is a partner in a Contractor organized as a partnership (Sections 1124(a)(2)(A) and 1903(m)(2)(A)(viii) of the Social Security Act and 42 CFR
455.100-104) 

  

	2.	The Name, Address, and Tax Identification Number of any corporation with an ownership or control interest in the Contractor, including those individuals who have direct, indirect, or combined direct/indirect
ownership interest of 5% or more of the Contractor’s equity, owns 5% or more of any mortgage, deed of trust, note, or other obligation secured by the Contractor if that interest equals at least 5% of the value of the Contractor’s assets,
is an officer or director of a Contractor organized as a corporation, or is a partner in a Contractor organized as a partnership (Sections 1124(a)(2)(A) and 1903(m)(2)(A)(viii) of the Social Security Act and 42 CFR 455.100-104). The address for
corporate entities must include as applicable primary business address, every business location, and P.O. Box address. 

  

	3.	Whether the person (individual or corporation) with an ownership or control interest in the Contractor is related to another person with ownership or control interest in the Contractor as a spouse, parent, child,
or sibling; or whether the person (individual or corporation) with an ownership or control interest in any subcontractor of the Contractor has a 5% or more interest is related to another person with ownership or control interest in the
Contractor as a spouse, parent, child, or sibling 

  

	4.	The name of any other disclosing entity as defined in 42 CFR 455.101 in which an owner of the Contractor has an ownership or control interest 


 

	5.	The Name, Address, Date of Birth and Social Security Number of any agent and managing employee (including Key Staff personnel as noted in Section D, paragraph 16) of the Contractor as defined in 42 CFR 455.101


 The Contractor shall also, with regard to its fiscal agents, obtain the following information regarding ownership and control [42 CFR
455.104]: 
  

	1.	The Name, Address, Date of Birth, and Social Security Numbers of any individual with an ownership or control interest in the fiscal agent 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

108 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	1.	The Name, Address, and Tax Identification Number of any corporation with an ownership or control interest in the fiscal agent. The address for corporate entities must include as applicable primary business
address, every business location, and P.O. Box address. 

  

	2.	Whether the person (individual or corporation) with an ownership or control interest in the fiscal agent is related to another person with ownership or control interest in the fiscal agent as a spouse, parent,
child, or sibling; or whether the person (individual or corporation) with an ownership or control interest in any subcontractor of the fiscal agent has a 5% or more interest is related to another person with ownership or control interest in
the fiscal agent as a spouse, parent, child, or sibling 

  

	3.	The name of any other disclosing entity as defined in 42 CFR 455.101 in which an owner of the fiscal agent has an ownership or control interest 


 

	4.	The Name, Address, Date of Birth and Social Security Number of any agent and managing employee of the fiscal agent as defined in 42 CFR 455.101. 


Disclosure of Information on Persons Convicted of Crimes [42 CFR 455.101through 106; 436][SMDL09-001]: 

The Contractor must do the following: 
  

	1.	Confirm the identity and determine the exclusion status of any person with an ownership or control interest in the Contractor, and any person who is an agent or managing employee of the Contractor (including Key Staff
personnel as noted in Section D, Paragraph 16), through routine checks of Federal databases; and 

  

	2.	Disclose the identity of any of these excluded persons, including those who have ever been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, or the Title
XX services program since the inception of those programs. 

 The Contractor shall, on a monthly basis, confirm the identity and determine the
exclusion status through routine checks of: 
  

	a.	The List of Excluded Individuals (LEIE) 

  

	b.	The System of Award Management (SAM) formerly known as the Excluded Parties List (EPLS) 

  

	c.	Any other databases directed by AHCCCS or CMS 

 The Contractor shall also, with regard to its fiscal agents,
identify, obtain and report the above information on persons convicted of crimes [42 CFR 455.101 through 106; 436] [SMDL09-001]. 
 The Contractor shall
provide the above-listed disclosure information to AHCCCS at any of the following times (Sections 1124(a)(2)(A) and 1903(m)(2)(A)(viii) of the Social Security Act, and 42 CFR 455.104(c)(3)):xxv

  

	1.	Upon the Contractor submitting the proposal in accordance with the State’s procurement process; 

  

	2.	Upon the Contractor executing the contract with the State; 

  

	3.	Within 35 days after any change in ownership of the Contractor; and 

  

	4.	Upon request by AHCCCS. 

 The results of the Disclosure of Ownership and Control and the Disclosure
of Information on Persons Convicted of Crimes shall be held by the Contractor. Upon renewal or extension of the contract, the Contractor shall submit an annual attestation as specified in Attachment F3, Contractor Chart of Deliverables, that the
information has been obtained and verified by the Contractor, or upon request, provide this information to AHCCCS. Refer to ACOM Policy 103 for further information.xxvi 

The Contractor must immediately notify AHCCCS-OIG of any person who has been excluded through these checks in accordance with the 42 CFR 455.106
(2)(b) and as specified in Attachment F3, Contractor Chart of Deliverables. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

109 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Federal Financial Participation (FFP) is not available for any amounts paid to a Contractor that could be
excluded from participation in Medicare or Medicaid for any of the following reasons:xxvii 
  

	1.	The Contractor is controlled by a sanctioned individual 

  

	2.	The Contractor has a contractual relationship that provides for the administration, management or provision of medical services, or the establishment of policies, or the provision of operational support for the
administration, management or provision of medical services, either directly or indirectly, with an individual convicted of certain crimes as described in Section 1128(b)(8)(B) of the Social Security Act. 


 

	3.	The Contractor employs or contracts, directly or indirectly, for the furnishing of health care, utilization review, medical social work, or administrative services, with one of the following: 


 

	 	a.	Any individual or entity excluded from participation in Federal health care programs 

  

	 	b.	Any entity that would provide those services through an excluded individual or entity (Section 1903(i)(2) of the Social Security Act, 42 CFR 431.55(h), 42 CFR 438.808, 42 CFR 1002.3(b)(3), SMD letter 6/12/08, and SMD
letter 1/16/09). 

 The Contractor shall require Administrative Services Subcontractors adhere to the requirements outlined above regarding
Disclosure of Ownership and Control and Disclosure of Information on Persons Convicted of Crimes as outlined in 42 CFR 455.101 through 106, 42 CFR 436 and SMDL09-001. Administrative Services Subcontractors shall disclose to AHCCCS-OIG the identity
of any excluded person. 
 In the event that AHCCCS-OIG, either through a civil monetary penalty or assessment, a global civil settlement or judgment, or
any other form of civil action, including recovery of an overpayment, receives a monetary recovery from an entity, the entirety of such monetary recovery belongs exclusively to AHCCCS and the Contractor has no claim to any portion of this recovery.
Furthermore, the Contractor is fully subrogated to AHCCCS for all civil recoveries. 
 In accordance with Section 1128A(a)(6) of the Act; and 42 CFR
section 1003.102(a)(2)(3) civil monetary penalties may be imposed against the Contractor, its subcontractors or providers who employ or enter into contracts with excluded individuals or entities to provide items or services to Medicaid recipients.

 The Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an
emergency room of a hospital) furnished under the plan by any individual or entity during any period when the individual or entity is excluded from participation under title V, XVIII, XIX, XX, or XXI pursuant to Sections 1128, 1128A, 1156, or
1842(j)(2) and (1903(i) and 1903(i)(2)(A)) of the Social Security Act.xxviii 
 The Contractor is
prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) furnished at the medical direction or on the prescription of a physician, during
the period when such physician is excluded from participation under title V, XVIII, XIX, XX, or XXI pursuant to section 1128, 1128A, 1156, or 1842(j)(2) of the Social Security Act and when the person furnishing such item or service knew, or had
reason to know, of the exclusion (after a reasonable time period after reasonable notice has been furnished to the person) (Sections 1903(i) and 1903(i)(2)(B))of the Social Security Act).xxix 

The Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an
emergency room of a hospital) furnished by an individual or entity to whom the state has failed to suspend payments during any period in which the state has notified the Contractor of a pending investigation of a credible allegation of fraud against
the individual or entity, unless the state determines there is good cause not to suspend such payments. (Section 1903(i) and 1903(i)(2)(C)) of the Social Security Act)xxx 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

110 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 63. RECORDS RETENTION 

The Contractor shall maintain records relating to covered services and expenditures including reports to AHCCCS and documentation used in the preparation of
reports to AHCCCS. The Contractor shall comply with all specifications for record keeping established by AHCCCS. All records shall be maintained to the extent and in such detail as required by AHCCCS rules and policies. Records shall include but not
be limited to financial statements, records relating to the quality of care, medical records, prescription files and other records specified by AHCCCS. 

The Contractor agrees to make available, at all reasonable times during the term of this contract, any of its records for inspection, audit or reproduction by
any authorized representative of AHCCCS, State or Federal government. The Contractor shall be responsible for any costs associated with the reproduction of requested information. 

The Contractor shall preserve and make available all records for a period of five years from the date of final payment under this contract unless a longer
period of time is required by law. For retention of patient medical records, the Contractor shall ensure compliance with A.R.S. §12-2297 which provides, in part, that a health care provider shall retain patient medical records according to the
following: 
  

	1.	If the patient is an adult, the provider shall retain the patient medical records for at least six years after the last date the adult patient received medical or health care services from that provider.


  

	2.	If the patient is under 18 years of age, the provider shall retain the patient medical records either for at least three years after the child’s eighteenth birthday or for at least six years after the last date the
child received medical or health care services from that provider, whichever date occurs later. 

 In addition, the Contractor shall comply
with the record retention periods specified in HIPAA laws and regulations, including, but not limited to, 45 CFR 164.530(j)(2). 
 If this Contract is
completely or partially terminated, the records relating to the work terminated shall be preserved and made available for a period of five years from the date of any such termination. Records which relate to grievances, disputes, litigation or the
settlement of claims arising out of the performance of this contract, or costs and expenses of this contract to which exception has been taken by AHCCCS, shall be retained by the Contractor for a period of five years after the date of final
disposition or resolution thereof. 
 64. SYSTEMS AND DATA EXCHANGE REQUIREMENTS 

The Contractor is required to exchange data with AHCCCS relating to the information requirements of this contract and as required to support the data elements
to be provided to AHCCCS. All data exchanged must be in the formats prescribed by AHCCCS, which include those required/covered by the Health Insurance Portability and Accountability Act (HIPAA). Details for the formats may be found in the HIPAA
Transaction Companion Guides, Trading Partner Agreements, AHCCCS Encounter Manual, and in the AHCCCS Technical Interface Guidelines, available on the AHCCCS website. 

The information exchanged with AHCCCS shall be in accordance with all procedures, policies, rules, or statutes in effect during the term of this contract. If
any of these procedures, policies, rules, regulations or statutes are hereinafter changed, both parties agree to conform to these changes following notification by AHCCCS. 

Electronic Transactions: The Contractor is required to accept and generate all required HIPAA compliant electronic transactions from or to any
provider or their assigned representative interested in and capable of electronic submission of eligibility verifications, claims, claims status verifications or prior authorization requests; or the receipt of electronic remittance. The Contractor
must be able to make claims payments via electronic funds transfer and have the capability to accept electronic claims attachments. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

111 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Contractor Data Exchange: Before a Contractor may exchange data with AHCCCS, certain
agreements, authorizations and control documents are required. The Contractor must have completed and submitted the EDI Trading Partner Agreement in order to exchange data with AHCCCS. 

Each Contractor is assigned a Transmission Submitter Number (TSN) for encounter submissions. The Contractor may elect to obtain additional TSNs based upon
processing or tracking needs. 
 Contractor Responsibilities: The Contractor is responsible for any incorrect data, delayed submission or
payment (to the Contractor or its subcontractors), and/or penalty applied due to any error, omission, deletion, or incorrect data submitted by the Contractor. Any data that does not meet the standards required by AHCCCS shall not be accepted by
AHCCCS. 
 The Contractor is required to provide an attestation that any data transmitted is accurate and truthful, to the best of the Contractor’s
Chief Executive Officer, Chief Financial Officer or designee’s knowledge [42 CFR 438.606] as outlined by AHCCCS. 
 The Contractor further agrees to
indemnify and hold harmless the State of Arizona and AHCCCS from any and all claims or liabilities, including but not limited to consequential damages, reimbursements or erroneous billings and reimbursements of attorney fees incurred as a
consequence of any error, omission, deletion or erroneous insert caused by the Contractor in the submitted input data. Neither the State of Arizona nor AHCCCS shall be responsible for any incorrect or delayed payment to the Contractor’s
providers (subcontractors) resulting from such error, omission, deletion, or erroneous input data caused by the Contractor in the submission of AHCCCS claims. 

The Contractor is also responsible for identifying any inconsistencies immediately upon receipt of data from AHCCCS. If any unreported inconsistencies are
subsequently discovered, the Contractor shall be responsible for the necessary adjustments to correct its records at its own expense. 
 Member
Data: The Contractor shall accept from AHCCCS original evidence of eligibility and enrollment in the AHCCCS prescribed electronic data exchange formats. Upon request, the Contractor shall provide to AHCCCS PCP assignments in an AHCCCS
prescribed electronic data exchange format. 
 Claims Data: This system must be capable of collecting, storing and producing information for
the purposes of financial, medical and operational management. 
 The Contractor shall develop and maintain a HIPAA compliant claims processing and payment
system capable of processing, cost avoiding and paying claims in accordance with A.R.S. §36-2903 and 2904 and AHCCCS rules A.A.C. R9-22 Article 7. The system must be adaptable to updates in order to support future AHCCCS claims related policy
requirements on a timely basis as needed. 
 On a recurring basis (no less than quarterly based on adjudication date), AHCCCS shall provide the Contractor
an electronic file of claims and encounter data for members enrolled with the Contractor who have received services, during the member’s enrollment period, from another contractor or through AHCCCS FFS for purposes of member care coordination.
Data sharing will comply with Federal privacy regulations. 
 In addition, the Contractor shall implement and meet the following milestones in order to make
claims processing and payment more efficient and timely: 
  

	1.	Receive 60% of each claim type (professional, institutional and dental) based on volume of actual claims excluding claims processed by Pharmacy Benefit Managers (PBMs) electronically. 


 

	2.	Produce and distribute 60% of remittances electronically. 

  

	3.	Provide 60% of claims payments via EFT. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

112 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 System Changes and Upgrades: The costs of software changes are included in administrative costs
paid to the Contractor. There is no separate payment for software changes. A PMMIS systems contact will be assigned after contract award. AHCCCS will work with the Contractor as they evaluate Electronic Data Interchange options. 

The Contractor will ensure that changing or making major upgrades to the information systems affecting claims processing, payment or any other major business
component, will be accompanied by a plan which includes a timeline, milestones, and outlines adequate testing to be completed before implementation. The Contractor shall notify and provide the system change plan to AHCCCS for review and comment as
specified in Attachment F3, Contractor Chart of Deliverables. 
 Health Insurance Portability and Accountability Act (HIPAA): The
Contractor shall comply with the Administrative Simplification requirements of 45 CFR Parts 160 and 162 that are applicable to the operations of the Contractor by the dates required by the implementing Federal regulations as well as all subsequent
requirements and regulations as published. 
 Data Security: The Contractor is required to have a security audit performed by an independent
third party on an annual basis. The annual audit report must be submitted to AHCCCS as specified in Attachment F3, Contractor Chart of Deliverables. 
 The
audit must include, at a minimum, a review of Contractor compliance with all security requirements as outlined in the AHCCCS Security Rule Compliance Summary Checklist, as specified in ACOM Policy 108. In addition, the audit must include a review of
Contractor policies and procedures to verify that appropriate security requirements have been adequately incorporated into the Contractor’s business practices, and the production processing systems. 

The audit must result in a findings report and as necessary a corrective action plan, detailing all issues and discrepancies between the security requirements
and the Contractor’s policies, practices and systems. The corrective action plan must also include timelines for corrective actions related to all issues or discrepancies identified. The annual report must include the findings and corrective
action plan and must be submitted to AHCCCS for review and approval. AHCCCS will verify that the required audit has been completed and the approved corrective action plan is in place and being followed as part of Operational Reviews. 

Health Information Exchange: The Contractor is required to contract with Health Information Network of Arizona (HINAz) as a data user. 

To further the integration of technology based solutions and the meaningful use of electronic health records within the system of care, AHCCCS will increase
opportunities for providers and Contractors to utilize technological functions for processes that are necessary to meet Medicaid requirements. Expanding the adoption may reduce total spending on health care by diminishing the number of inappropriate
tests and procedures, reducing paperwork and administrative overhead, and decreasing the number of adverse events resulting from medical errors. The Contractor will actively participate in offering information and providing provider support and
education to further expand provider adoption and use of health information technology. It is AHCCCS’ expectation that the Contractor review operational processes to reduce provider hassle factors by implementing technological solutions for
those providers utilizing electronic health records and to incentivize providers to implement and meaningfully use health information technology as a standard of doing business with the AHCCCS program. AHCCCS also anticipates establishing
minimum standards, goals and requirements related to operational areas where improved efficiencies or effectiveness could be achieved. AHCCCS anticipates accelerating statewide Health Information Exchange (HIE) participation for all Medicaid
providers and Contractors by: 
  

	 	•	 	Supporting care coordination between physical and behavioral health providers 

  

	 	•	 	Launching an HIE onboarding program for high volume Medicaid hospitals, Federally Qualified Health Centers, Rural Health Clinics and Look-a-Likes 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

113 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	 	•	 	Supporting the acceleration of electronic prescribing by Arizona Medicaid providers 

  

	 	•	 	Joining the State level HIE for governance, policy making, and information technology service offerings 

  

	 	•	 	Supporting increased Contractor use of the Network (State HIE) to improve health outcomes 

  

	 	•	 	Identifying value-based purchasing opportunities that link with a providers adoption and use of Health IT 


The Contractor is expected to encourage that eligible hospitals and eligible professionals continue to move through the Meaningful Use continuum, accelerate
provider statewide HIE participation, and increase use and support of the HIT/HIE. The Contractor is expected to collaborate with AHCCCS and Arizona Health-e Connection and The Network to target efforts to specific areas where HIT and HIE
can bring significant change and progress including efforts focused on: 
  

	 	•	 	Behavioral health 

  

	 	•	 	Partnerships for integrated care 

  

	 	•	 	High need/high cost members 

  

	 	•	 	Coordination with the American Indian Health Program 

  

	 	•	 	Coordination with the Qualified Health Plans 

  

	 	•	 	Justice system transitions 

  

	 	•	 	Care coordination 

  

	 	•	 	Pharmacy management 

  

	 	•	 	Quality improvement 

 65. ENCOUNTER DATA REPORTING 

Complete, accurate and timely reporting of encounter data is crucial to the success of the AHCCCS program. AHCCCS uses encounter data to pay reinsurance
benefits, set Fee-For-Service and capitation rates, determine reconciliation amounts, determine disproportionate share payments to hospitals, and to determine compliance with performance standards. The Contractor shall submit encounter data to
AHCCCS for all services for which the Contractor incurred a financial liability and claims for services eligible for processing by the Contractor where no financial liability was incurred including services provided during prior period coverage.
This requirement is a condition of the CMS grant award [42 CFR 438.242(b)(1)][42 CFR 455.1 (a)(2)]. 
 New Contractors must successfully exchange encounter
data for all applicable form types with AHCCCS no later than 120 days after the start of the contract or be subject to possible corrective actions up to and including sanctions and enrollment caps. 

Encounter Submissions: Encounters must be submitted in the format prescribed by AHCCCS. Encounter data must be provided to AHCCCS as outlined in
the HIPAA Transaction Companion Guides, Trading Partner Agreements and the AHCCCS Encounter Manual, including, but not limited to, inclusion of data to identify the physician who delivers services to patients per Section 1903(m)(2)(A)(xi)) of
the Social Security Act.xxxi 
 Professional, Institutional and Dental Encounters not involving
services eligible for Federal Drug Rebate processing should be received by AHCCCS no later than 240 days after the end of the month in which the service was rendered, or the effective date of the enrollment with the Contractor, whichever date is
later. 
 Covered outpatient drugs dispensed to individuals eligible for medical assistance who are enrolled with the Contractor shall be subject to the
same rebate requirements as the State is subject under Section 1927 of the Social Security Act; the State shall collect such rebates from manufacturers (Section 1903(m)(2)(A)(xiii) of the Social Security Act and SMD letter 10-006).xxxii To ensure AHCCCS compliance with this requirement, pharmacy related encounter data and other encounters involving services eligible for Federal Drug Rebate processing must be provided to AHCCCS
no later than 30 days after the end of the quarter in which the pharmaceutical item was dispensed. The Contractor must report information on the total number of units of 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

114 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 
each dosage form and strength and package size by National Drug Code of each covered outpatient drug dispensed (other than covered outpatient drugs that under subsection (j)(1) of
Section 1927 of the Social Security Act [42 USCS § 1396r-8] are not subject to the requirements of that section) and such other data as required by AHCCCS (Section1903(m)(2)(A)(xiii) of the Social Security Act and SMD letter 10-006).xxxiii 
 A Contractor shall prepare, review, verify, certify, and submit, encounters for consideration to
AHCCCS. Upon submission, the Contractor must provide attestation that the services listed were actually rendered. 
 The Contractor may be assessed
sanctions for noncompliance with encounter submission completeness, accuracy and timeliness requirements. 
 Encounter Reporting: The
Contractor must produce reports for the purposes of tracking, trending, reporting process improvement and monitoring submissions and revisions of encounters. The Contractor will submit these reports to AHCCCS as required per the AHCCCS Encounter
Manual or as directed by AHCCCS and as further specified in Attachment F3, Contractor Chart of Deliverables. 
 On a monthly basis AHCCCS will produce
encounter reconciliation files containing the prior 18 months of approved, voided, plan-denied, pended and AHCCCS-denied encounters received and processed by AHCCCS. These files must be utilized to compare the encounter financial data reported with
plan claims data, and to compare submitted encounters to processed claims to validate completeness of encounter submissions. 
 Encounter Supporting
Data Files: AHCCCS provides the Contractor with periodic (no less than twice monthly) full replacement files containing provider and medical coding information as stored in PMMIS. These files should be used by the Contractor to ensure
accurate Encounter Reporting. Refer to the AHCCCS Encounter Manual for further information regarding the content and layouts of these files. 

Encounter Corrections: The Contractor is required to monitor and resolve pended encounters and encounters denied by AHCCCS. 

The Contractor is further required to submit replacement or voided encounters in the event that claims are subsequently corrected following the initial
encounter submission. This includes corrections as a result of inaccuracies identified by fraud and abuse audits or investigations conducted by AHCCCS or the Contractor. The Contractor must void encounters for claims that are recouped in full. For
recoupments that result in a reduced claim value or adjustments that result in an increased claim value, replacement encounters must be submitted. Refer to the AHCCCS Encounter Manual for instructions regarding the submission of corrected, replaced
or voided encounters. 
 Encounter Performance Standards: AHCCCS has established encounter performance standards as detailed in
the AHCCCS Encounter Manual. All encounters including approved, pended, denied and voided encounters, impact completeness, accuracy, and timeliness rates. Rates below the established standards (pended encounters that have pended
for more than 120 days for example), or poor encounter performance overall, may result in Corrective Action Plans and/or sanctions. 

Encounter Validation Studies: Per CMS requirements, AHCCCS will conduct encounter validation studies of the Contractor’s encounter
submissions. These studies may result in sanctions of the Contractor and/or require a corrective action plan for noncompliance with related encounter submission requirements. 

The purpose of encounter validation studies is to compare recorded utilization information from a medical record or other source with the Contractor’s
submitted encounter data. Any and all covered services may be validated as part of these studies. The criteria used in encounter validation studies may include timeliness, correctness and omission of encounters. Refer to the AHCCCS Data Validation
Technical Document for further information. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

115 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 AHCCCS may revise study methodology, timelines and sanction amounts based on agency review or as a result of
consultations with CMS. The Contractor will be notified in writing of any significant change in study methodology. 
 66. ENROLLMENT AND CAPITATION
TRANSACTION UPDATES 
 AHCCCS produces daily enrollment transaction updates identifying new members and changes to existing members’ demographic,
eligibility and enrollment data as outlined in the HIPAA Transaction Companion Guides, Trading Partner Agreements, and the AHCCCS Technical Interface Guidelines available on the AHCCCS website. These files shall be utilized by the Contractor to
update its member records on a timely and consistent basis. The daily enrollment transaction update, that is run immediately prior to the monthly enrollment and capitation transaction, is referred to as the “last daily” and will contain
all rate code changes made for the prospective month, as well as any new enrollments and disenrollments as of the first of the prospective month. 
 AHCCCS
also produces a daily Manual Payment Transaction as outlined in the AHCCCS Technical Interface Guidelines, available on the AHCCCS website, which identifies enrollment or disenrollment activity that was not included on the daily enrollment
transaction update due to internal edits. The Contractor shall use the Manual Payment Transaction in addition to the daily enrollment transaction update to update its member records. 

A weekly capitation transaction as outlined in the HIPAA Transaction Companion Guides, and Trading Partner Agreements, will be produced to provide the
Contractor with member-level capitation payment information. This file will show changes to the prospective capitation payments, as sent in the monthly file, resulting from enrollment changes that occur after the monthly file is produced. This file
will also identify mass adjustments to and/or manual capitation payments that occurred at AHCCCS after the monthly file is produced. 
 On a daily and
monthly basis AHCCCS provides the Contractor with the Rate Code Summary electronic file as outlined in the AHCCCS Technical Interface Guidelines, available on the AHCCCS website, which summarizes the capitation activity for the processing cycle.

 The enrollment and capitation transaction updates distributed monthly are generally produced two days before the end of every month. The update will
identify the total active population for the Contractor as of the first day of the next month. These updates contain the information used by AHCCCS to produce the monthly capitation payment for the next month. The Contractor must reconcile the
member files (including the member’s Medicare status, TPL information, etc.) with the AHCCCS monthly update. After reconciling the monthly update information, the Contractor will work to resolve any discrepancies and record the results of the
reconciliation. Results of the reconciliation will be made available to AHCCCS upon request. After completion of the reconciliation the Contractor will resume posting daily updates beginning with the last two days of the month. The last two daily
updates are different from the regular daily updates in that they pay and/or recoup capitation for the next month. If the Contractor detects an error through the monthly update process, the Contractor shall notify AHCCCS, Information Services
Division. 
 67. PERIODIC REPORTING REQUIREMENTS 
 Under
the terms and conditions of its CMS grant award, AHCCCS requires periodic reports, encounter data and other information from the Contractor. The submission of late, inaccurate, or otherwise incomplete reports shall constitute failure to report
subject to the penalty provisions described in Section D, Paragraph 72, Sanctions. 
 Standards applied for determining adequacy of required reports are as
follows [42 CFR 438.242(b)(2)]: 
  

	a.	Timeliness: Reports or other required data shall be received on or before scheduled due dates. 

  

	b.	Accuracy: Reports or other required data shall be prepared in strict conformity with appropriate authoritative sources and/or AHCCCS defined standards. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

116 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	c.	Completeness: All required information shall be fully disclosed in a manner that is both responsive and pertinent to report intent with no material omissions. 


The Contractor shall comply with all reporting requirements contained in this contract. AHCCCS requirements regarding reports, including but not limited to,
report content, report frequency, and report submission, are subject to change at any time during the term of the contract. The Contractor shall comply with all changes specified by AHCCCS, including those pertaining to subcontractor and provider
reporting requirements. The Contractor shall be responsible for continued reporting beyond the term of the contract. 
 68. REQUESTS FOR INFORMATION

 AHCCCS may, at any time during the term of this contract, request financial or other information from the Contractor. Responses shall fully disclose
all financial or other information requested. Information may be designated as confidential but may not be withheld from AHCCCS as proprietary. Information designated as confidential may not be disclosed by AHCCCS without the prior written consent
of the Contractor except as required by law. Upon receipt of such requests for information from AHCCCS, the Contractor shall provide complete information to AHCCCS as requested no later than 20 days after the receipt of the request unless otherwise
specified in the request itself. 
 If the Contractor believes the requested information is confidential and may not be disclosed to third parties, the
Contractor shall provide a detailed legal analysis to AHCCCS, within the timeframe designated by AHCCCS, setting forth the specific reasons why the information is confidential and describing the specific harm or injury that would result from
disclosure. In the event that AHCCCS withholds information from a third party as a result of the Contractor’s statement, the Contractor shall be responsible for all costs associated with the nondisclosure, including but not limited to legal
fees and costs. 
 69. DISSEMINATION OF INFORMATION 

Upon request, the Contractor shall disseminate information prepared by AHCCCS or the Federal government to its members and all costs shall be the
responsibility of the Contractor. All advertisements, publications and printed materials that are produced by the Contractor and refer to covered services shall state that such services are funded under contract with AHCCCS. 

70. OPERATIONAL AND FINANCIAL READINESS REVIEWS 
 AHCCCS
will conduct an Operational and Financial Readiness Review of the Contractor and will, subject to the availability of resources, provide technical assistance as appropriate. The Readiness Review will be conducted prior to the start of business. The
purpose of a Readiness Review is to assess the Contractor’s operational readiness and its ability to provide covered services to members at the start of the contract year. The Contractor will be permitted to commence operations only if the
Readiness Review factors are met to AHCCCS’ satisfaction. 
 71. MONITORING AND OPERATIONAL REVIEWS 

The Contractor shall comply with all reporting requirements contained in this Contract and AHCCCS policy. In accordance with CMS requirements, AHCCCS has in
effect procedures for monitoring the Contractors’ operations to ensure program compliance and identify best practices, including, but not limited to, evaluation of submitted deliverables, ad hoc reporting, and periodic focused and operational
reviews.xxxiv 
 These monitoring procedures will include, but are not limited to, operations related
to the following:xxxv 
  

	a.	Member enrollment and disenrollment; 

  

	b.	Processing grievances and appeals; 

  

	c.	Violations subject to intermediate sanctions, as set forth in Subpart I of 42 CFR 438; 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

117 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	d.	Violations of the conditions for receiving federal financial participation, as set forth in Subpart J of 42 CFR 438; and 

  

	e.	All other provisions of the contract, as appropriate. [42 CFR 438.66(a)] 

 Operational Reviews:
In accordance with CMS requirements [42 CFR 434.6(a)(5)] and Arizona Administrative Code [Title 9, A.A.C. Chapter 22 Article 5], AHCCCS, or an independent agent, will conduct periodic Operational Reviews to ensure program compliance and identify
best practices [42 CFR 438.204]. 
 The reviews will identify and make recommendations for areas of improvement, monitor the Contractor’s progress
towards implementing mandated programs or operational enhancements, and provide the Contractor with technical assistance when necessary. The type and duration of the review will be solely at the discretion of AHCCCS. 

Except in cases where advance notice is not possible or advance notice may render the review less useful, AHCCCS will give the Contractor at least three weeks
advance notice of the date of the scheduled Operational Review. AHCCCS reserves the right to conduct reviews without notice to monitor contractual requirements and performance as needed. 

AHCCCS may request, at the expense of the Contractor, to conduct on-site reviews of functions performed at out of State locations and will coordinate travel
arrangements and accommodations with the Contractor. 
 In preparation for the reviews, the Contractor shall cooperate with AHCCCS by forwarding in advance
policies, procedures, job descriptions, contracts, records, logs and other material upon request. Documents not requested in advance shall be made available during the course of the review. Contractor personnel shall be available at all times during
review activities. The Contractor shall provide an appropriate private workspace and internet access. 
 The Contractor will be furnished a copy of the
draft Operational Review report and given an opportunity to comment on any review findings prior to AHCCCS issuing the final report. The Contractor must develop corrective action plans based on these recommendations. The corrective action plans and
modifications to the corrective action plans must be approved by AHCCCS. Unannounced follow-up reviews may be conducted at any time after the initial Operational Review to determine the Contractor’s progress in implementing recommendations and
achieving compliance. 
 The Contractor shall not distribute or otherwise make available the Operational Review Tool, draft Operational Review Report or
final report to other Contractors. 
 72. SANCTIONS 
 In
accordance with applicable Federal and State regulations, A.A.C. R9-22-606, ACOM Policy 408 and the terms of this contract, AHCCCS may impose sanctions for failure to comply with any provision of this contract. Written notice will be provided to the
Contractor specifying the sanction to be imposed, the grounds for such sanction and either the length of suspension or the amount of capitation to be withheld. The Contractor may dispute the decision to impose a sanction in accordance with the
process outlined in A.A.C. R9-34-401 et seq. 
 Cure Notice Process: AHCCCS may provide a written cure notice to the Contractor regarding the
details of the non-compliance. If a notice to cure is provided to the Contractor, the cure notice will specify the period of time during which the Contractor must bring its performance back into compliance with contract requirements. If, at the end
of the specified time period, the Contractor has complied with the cure notice requirements, AHCCCS will not impose a sanction. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

118 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 AHCCCS may impose sanctions including but not limited to: 

 

	a.	Civil monetary penalties. 

  

	b.	Appointment of temporary management for a Contractor as provided in 42 CFR 438.706 and A.R.S. §36-2903 (M). 

  

	c.	Granting members the right to terminate enrollment without cause and notifying the affected members of their right to disenroll [42 CFR 438.702(a)(3); 42 CFR 438.722]. 


 

	d.	Suspension of all new enrollments, including auto assignments after the effective date of the sanction. 

  

	e.	Suspension of payment for recipients enrolled after the effective date of the sanction until CMS or AHCCCS is satisfied that the reason for imposition of the sanction no longer exists and is not likely to recur.


  

	f.	Additional sanctions allowed under statute or regulation that address areas of noncompliance. 

 Refer to ACOM
Policy 408 for details. 
 Automatic Sanctions: AHCCCS will assess the sanctions listed in Attachment F3, Contractor Chart of Deliverables on
deliverables listed under DHCM Operations, Clinical Quality Management and Medical Management that are not received by 5:00 PM on the due date indicated. If the due date falls on a weekend or a State Holiday, sanctions will be assessed on
deliverables not received by 5:00 PM on the next business day. 
 73. BUSINESS CONTINUITY AND RECOVERY PLAN 

The Contractor shall develop a Business Continuity and Recovery Plan as detailed in ACOM Policy 104, to deal with unexpected events that may affect its
ability to adequately serve members. All staff shall be trained on, and familiar with, the Plan. This Plan shall, at a minimum, include planning and training for: 
  

	 	•	 	Electronic/telephonic failure at the Contractor’s main place of business 

  

	 	•	 	Complete loss of use of the main site and satellite offices out of State 

  

	 	•	 	Loss of primary computer system/records 

  

	 	•	 	Communication between the Contractor and AHCCCS in the event of a business disruption 

  

	 	•	 	Periodic Testing (at least annually) 

 The Business Continuity and Recovery Plan shall be updated annually. The
Contractor shall submit a summary of the Plan to AHCCCS as specified in Attachment F3, Contractor Chart of Deliverables. 
 74. MEDICARE REQUIREMENTS

 Medicare Coordination for Dual Eligible Members 

Background Information: In an effort to improve care coordination for AHCCCS dual eligible members, AHCCCS requires the Contractor, or its
corporate affiliate, to be a Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) in all GSAs in which they hold a contract. To match the population served, the D-SNP Type must be a dual eligbile subset non-zero cost share that matches this
contract. 
 Medicare Structure: As required by A.R.S. §36-2906.01, the awarded Contractor must establish a separate corporation whose
only authorized business is to provide services under this contract or other contracts with AHCCCS and the Medicare product to the extent necessary to ensure integration of AHCCCS and Medicare services for persons enrolled with the Contractor for
both programs. The Contractor must have, and assure AHCCCS it has, the legal and actual authority to direct, manage, and control the operations of both the corporation established under this contract and the Medicare product to the extent necessary
to ensure integration of AHCCCS and Medicare services for persons enrolled with the Contractor for both programs. The Contractor must ensure the integration of Medicare and Medicaid services within the following key functional areas of the
organization or when utilizing administrative services subcontracts: 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

119 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  


	 	•	 	Network Management/Provider Relations; 

  

	 	•	 	Member Services; 

  

	 	•	 	Quality Management; 

  

	 	•	 	Medical Management; 

  

	 	•	 	Corporate Compliance; and 

  

	 	•	 	Grievance System. 

 Medicare Branding: The Contractor must establish branding for the Medicare
product that ensures it is easily identifiable to members and providers as an integrated plan for both Medicare and Medicaid. 
 Medicare State
Certification: Medicare Advantage plans are required to be licensed under State law. As outlined in A.R.S §36-2903(B)(2) AHCCCS has the authority to certify its Contractors for Medicare purposes. Contractors are able to apply for
certification through AHCCCS or apply and receive licensure through the Arizona Department of Insurance. The AHCCCS certification process is detailed in ACOM 313. 

State Contracting with D-SNPs: Per ACOM Policy 107, AHCCCS will not contract with any D-SNP to serve the Acute Care Medicaid population outside
of awarded Acute Care contracts. Detailed D-SNP responsibilities are outlined in Medicare Advantage D SNP Health Plan Agreement. 
 Alignment
Efforts: Dual eligible members may be assigned to a Medicaid plan based on their Medicare D-SNP enrollment. Aligning Medicare and Medicaid plans ensures a more coordinated process for members and providers. AHCCCS will continue to pursue
policies and practices which improve the system for dual eligible members including, but not limited to: 
  

	 	•	 	On an ongoing basis, aligning Medicaid enrollment with Medicare; 

  

	 	•	 	Working with community stakeholders for outreach and education; 

  

	 	•	 	Conducting state sponsored outreach and education; 

  

	 	•	 	Requiring plan outreach and education. 

 Effective October 1, 2015, Acute Care Contractors are responsible
for the provision and coordination of general mental health and substance abuse behavioral health services for adult members in any Medicare arrangement who are age 18 and older. 

The Contractor shall provide seamless conversion enrollment of newly Medicare eligible individuals who are currently enrolled with the Contractor for Medicaid
only, into the Contractor’s companion D-SNP, subject to CMS approval. This directive is based on CMS guidance provided in the Medicare Managed Care Manual, Chapter 2, Section 40.1.4 and will include individuals who have aged-in to Medicare
as well as those qualified for Medicare upon the completion of the 24 month waiting period due to a disability. 
 75. PENDING LEGISLATION/OTHER ISSUES

 The following constitute pending items that may be resolved after the issuance of this contract. Any program changes due to the resolution of the
issues will be reflected in future amendments to the contract. Capitation rates may also be adjusted to reflect the financial impact of program changes. The items in this paragraph are subject to change and should not be considered all-inclusive.

 Federal and State Legislation: AHCCCS and its Contractors are subject to legislative mandates that may result in changes to
the program. AHCCCS will either amend the contract or incorporate changes in policies incorporated in the contract by reference. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

120 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 Patient Protection and Affordable Care Act: The Contractor shall comply with the applicable
sections of the Patient Protection and Affordable Care Act (PPACA) including, but not limited to, the Health Insurer Fee and including those provisions as adopted by AHCCCS in the Arizona State Plan. The Contractor shall provide services to Medicaid
eligible individuals who will be covered by the Medicaid restoration and expansion starting January 1, 2014. Additionally, upon CMS approval, AHCCCS will implement modifications to cost sharing requirements, including but not limited to, the
populations currently subject to mandatory and optional (nominal) copayments, copayment amounts, and services for which copays are required. The effective date of these provisions will be communicated after CMS approval. AHCCCS will provide the
Contractor time to modify systems and address member and provider communications. 
 Hospital Presumptive Eligibility: As required under the
Affordable Care Act, AHCCCS has established standards for the State’s Hospital Presumptive Eligibility (HPE) program in accordance with federal requirements. Qualified hospitals that elect to participate in the HPE Program will implement a
process consistent with AHCCCS standards which determines applicants presumptively eligible for AHCCCS acute care covered services. Persons determined presumptively eligible who have not submitted a full application to AHCCCS will qualify
for acute care services from the date the hospital determines the individual to be presumptively eligible through the last day of the month following the month in which the determination of presumptive eligibility was made by the qualified hospital.
For persons who apply for presumptive eligibility and who also submit a full application to AHCCCS, coverage of acute care services will begin on the date that the hospital determines the individual to be presumptively eligible and will
continue through the date that AHCCCS issues a determination on that application. All persons determined presumptively eligible for AHCCCS will be enrolled with AHCCCS Fee-For-Service for the duration of the HPE eligibility period. If a member
made eligible via HPE is subsequently determined eligible for AHCCCS via the full application process, Prior Period Coverage for the member will also be covered by AHCCCS Fee-For-Service, and the member will be enrolled with the Contractor only
on a prospective basis. AHCCCS is awaiting Federal approval of its HPE State Plan Amendment and policy and will share more information on the HPE program when it becomes available.

Zip Code Alignment: Effective on or about August 1, 2015, AHCCCS will move zip codes 85542, 85192, and 85550 from the GSA which includes
Gila County to the GSA which includes Graham County. This change is being implemented to keep zip code assignment consistent between AHCCCS lines of business. As part of the Greater AZ Integrated RBHAs effective October 1, 2015, this move
is occurring to align tribal members from a single tribe into a single RBHA when, today, the tribe currently spans multiple GSAs, and thus tribal members are managed by multiple RBHAs. 

Administrative Simplification: Arizona Laws 2015, Chapter 19, Section 9 (SB 1480) enacts that from and after June 30, 2016, the
provision of behavioral health services under the Division of Behavioral Health Services (DBHS) in the Department of Health Services is transferred to and shall be administered by the Arizona Health Care Cost Containment System (AHCCCS). From and
after June 30, 2016, the AHCCCS administration succeeds to the authority, powers, duties and responsibilities of DBHS with the exception of the Arizona State Hospital. This act does not alter the effect of any actions or impair the valid
obligations of DBHS taken before July 1, 2016. Administrative rules and orders that were adopted by DBHS continue in effect until superseded by administrative action by AHCCCS. Until administrative action is taken by AHCCCS, any reference
to DBHS in rules and orders is considered to refer to AHCCCS. All administrative matters, contracts and judicial and quasi-judicial actions, whether completed, pending or in process, of DBHS on July 1, 2016 are transferred to and retain the
same status with AHCCCS. AHCCCS and DBHS will work to administratively streamline contractual oversight and monitoring of the Tribal and Regional Behavioral Health Authorities (T/RBHAs) throughout Arizona, pursue continuous quality improvement, and
reduce fragmentation in healthcare delivery to develop an integrated system of healthcare. This merger will not impact what services are offered to members or how services are delivered. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

121 










			
	SECTION D: ACUTE CARE PROGRAM REQUIREMENTS	 	Contract No. YH14-0001

  

 
  

 76. VALUE-BASED PURCHASING 

Value-Based Purchasing (VBP) is a cornerstone of AHCCCS’ strategy to bend the upward trajectory of health care costs. AHCCCS is implementing initiatives
to leverage the managed care model toward value based health care systems where members’ experience and population health are improved, per-capita health care cost is limited to the rate of general inflation through aligned incentives with
managed care organization and provider partners, and there is a commitment to continuous quality improvement and learning. The Contractor shall participate in payment VBP efforts. 

Value-Based Purchasing Initiative: The purpose of the VBP initiative is to encourage Contractor activity in the area of quality improvement by
aligning the incentives of the Contractor and provider through VBP strategies, as delineated by ACOM Policy 315 CYE 16 and as specified in Attachment F3, Contractor Chart of Deliverables. Quality distributions to Contractors will be funded by
assessing 1 percent from Prospective Gross Capitation (Quality Contribution) exclusive of Delivery Supplemental, KidsCare and State Only Transplant payments. One hundred percent (100%) of the Quality Contributions will be distributed to one or
more Contractors according to the Contractors’ performance on selected Quality Management Performance Measures relative to minimum performance standards established by CQM and the Contractors’ ranking on QMPMs. Quality contributions and
quality distributions will be settled through a reconciliation performed annually on a contract year basis. 
 Value-Based Providers: The
Contractor shall develop strategies that ensure that members are directed to providers who participate in VBP initiatives and who offer value as determined by measureable outcomes. The Contractor shall submit by October 31, 2015, an Executive
Summary describing its strategies to direct members to valued providers. 
 E-Prescribing: E-Prescribing is an effective tool to improve
members’ health outcomes and reduce costs as delineated in ACOM Policy 321. Benefits afforded by the electronic transmission of prescription-related information include, but are not limited to: reduced medication errors, reductions of drug and
allergy interactions and therapeutic duplication, and increased prescription accuracy. The Contractor shall increase its E-Prescribing rate of original prescriptions in accordance with ACOM Policy 321. 

The Prescription Origin Code and Fill Number (Original or Refill Dispensing) must be submitted on all pharmacy encounter records, as outlined in the AHCCCS
NCPDP Post Adjudicated History Transaction Companion Guide, in order for AHCCCS to measure the Contractor’s success. 
 Centers of
Excellence: Centers of Excellence are facilities that are recognized as providing the highest levels of leadership, quality, and service. Centers of Excellence align physicians and other providers to achieve higher value through greater
focus on appropriateness of care, clinical excellence, and patient satisfaction. Designation as a Center of Excellence is based on criteria such as procedure volumes, clinical outcomes, and treatment planning and coordination. To encourage
Contractor activity which incentivizes utilization of the best value providers for select, evidenced based, high volume procedures or conditions, the Contractor shall submit a Centers of Excellence Report to AHCCCS, DHCM by April 1, 2016, as
specified in Attachment F3, Contractor Chart of Deliverables, outlining the Contractor’s approach to developing at least two Centers of Excellence for at least two different procedures or conditions. The Centers of Excellence Report must: 

 

	a.	Identify why the selected procedures or conditions were chosen, 

  

	b.	Outline how the Contractor will identify and select providers with the highest quality outcomes, 

  

	c.	Provide a high-level summary of potential contracting approaches, 

  

	d.	Identify how the Contractor plans to drive utilization to the Centers of Excellence, and 

  

	e.	Identify any barriers or challenges with the development of such Centers of Excellence. 

 [END OF SECTION D]


  
 Acute Care Contract 

10/01/2015 Renewal 
  

122 









			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  

SECTION E: CONTRACT TERMS AND CONDITIONS 
 1.
ADVERTISING AND PROMOTION OF CONTRACT 
 The Contractor shall not advertise or publish information for commercial benefit concerning this contract
without the prior written approval of the Contracting Officer. 
 2. APPLICABLE LAW 

Arizona Law - The law of Arizona applies to this contract including, where applicable, the Uniform Commercial Code, as adopted in the State of Arizona. 

Implied Contract Terms - Each provision of law and any terms required by law to be in this contract are a part of this contract as if fully stated in it. 

3. ARBITRATION 
 The parties to this contract agree to
resolve all disputes arising out of or relating to this contract through arbitration, after exhausting applicable administrative review, to the extent required by A.R.S. §12-1518 except as may be required by other applicable statutes. 

4. ASSIGNMENT AND DELEGATION 
 The Contractor shall not
assign any rights nor delegate all of the duties under this contract. Delegation of less than all of the duties of this contract must conform to the requirements of Section D, Subcontracts. 

5. ASSIGNMENT OF CONTRACT AND BANKRUPTCY 
 This contract
is voidable and subject to immediate cancellation by AHCCCS upon the Contractor becoming insolvent or filing proceedings in bankruptcy or reorganization under the United States Code, or assigning rights or obligations under this contract without the
prior written consent of AHCCCS. 
 6. AUDITS AND INSPECTIONS 

The Contractor shall comply with all provisions specified in applicable A.R.S. §35-214 and §35-215 and AHCCCS rules and policies and procedures
relating to the audit of the Contractor’s records and the inspection of the Contractor’s facilities. The Contractor shall fully cooperate with AHCCCS staff and allow them reasonable access to the Contractor’s staff, subcontractors,
members, and records [42 CFR 438.6(g)]. 
 At any time during the term of this contract, and five (5) years thereafter unless a longer time is
otherwise required by law, the Contractor’s or any subcontractor’s books and records shall be subject to audit by AHCCCS and, where applicable, the Federal government, to the extent that the books and records relate to the performance of
the contract or subcontracts [42 CFR 438.242(b)(3)]. 
 AHCCCS, or its duly authorized agents, and the Federal government may evaluate through on-site
inspection or other means, the quality, appropriateness and timeliness of services performed under this contract. 
 7. AUTHORITY 

This contract is issued under the authority of the Contracting Officer who signed this contract. Changes to the contract, including the addition of work or
materials, the revision of payment terms, or the substitution of work or materials, directed by an unauthorized state employee or made unilaterally by the Contractor are violations of the contract and of applicable law. Such changes, including
unauthorized written contract amendments, shall be void and without effect, and the Contractor shall not be entitled to any claim under this contract based on those changes. 

8. CHANGES 
 AHCCCS may at any time, by written notice to
the Contractor, make changes within the general scope of this contract. If any such change causes an increase or decrease in the cost of, or the time required for, performance of any part of the work under this contract, the Contractor may assert
its right to an adjustment in 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

123 










			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  

 
compensation paid under this contract. The Contractor must assert its right to such adjustment within 30 days from the date of receipt of the change notice. Any dispute or disagreement caused by
such notice shall constitute a dispute within the meaning of Section E, Disputes, and be administered accordingly. 
 When AHCCCS issues an amendment to
modify the contract, the provisions of such amendment will be deemed to have been accepted 30 days after the date of mailing by AHCCCS, even if the amendment has not been signed by the Contractor, unless within that time the Contractor notifies
AHCCCS in writing that it refuses to sign the amendment. If the Contractor provides such notification, AHCCCS will initiate termination proceedings. 

9. CHOICE OF FORUM 
 The parties agree that jurisdiction
over any action arising out of or relating to this contract shall be brought or filed in a court of competent jurisdiction located in the State of Arizona. 

10. COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS 

The Contractor shall comply with all applicable Federal and State laws and regulations including Title VI of the Civil Rights Act of 1964; Title IX of the
Education Amendments of 1972 (regarding education programs and activities); the Age Discrimination Act of 1975; the Rehabilitation Act of 1973 (regarding education programs and activities), and the Americans with Disabilities Act; EEO provisions;
Copeland Anti-Kickback Act; Davis-Bacon Act; Contract Work Hours and Safety Standards; Rights to Inventions Made Under a Contract or Agreement; Clean Air Act and Federal Water Pollution Control Act; Byrd Anti-Lobbying Amendment. The Contractor shall
maintain all applicable licenses and permits. 
 11. CONFIDENTIALITY AND DISCLOSURE OF CONFIDENTIAL INFORMATION 

The Contractor shall safeguard confidential information in accordance with Federal and State laws and regulations, including but not limited to, 42 CFR 431,
Subpart F, A.R.S. §36-107, §36-2903 (for Acute), §36-2932 (for ALTCS), §41-1959 and §46-135, the Health Insurance Portability and Accountability Act (Public Law 107-191 Statutes 1936), 45 CFR parts 160 and 164, and AHCCCS
Rules. 
 The Contractor shall establish and maintain procedures and controls that are acceptable to AHCCCS for the purpose of assuring that no information
contained in its records or obtained from AHCCCS or others carrying out its functions under the contract shall be used or disclosed by its agents, officers or employees, except as required to efficiently perform duties under the contract. Except as
required or permitted by law, the Contractor also agrees that any information pertaining to individual persons shall not be divulged other than to employees or officers of the Contractor as needed for the performance of duties under the contract,
unless otherwise agreed to, in writing, by AHCCCS. 
 The Contractor shall not, without prior written approval from AHCCCS, either during or after the
performance of the services required by this contract, use, other than for such performance, or disclose to any person other than AHCCCS personnel with a need to know, any information, data, material, or exhibits created, developed, produced, or
otherwise obtained during the course of the work required by this contract. This nondisclosure requirement shall also pertain to any information contained in reports, documents, or other records furnished to the Contractor by AHCCCS. 

12. CONFLICT OF INTEREST 
 The Contractor shall not
undertake any work that represents a potential conflict of interest, or which is not in the best interest of AHCCCS or the State without prior written approval by AHCCCS. The Contractor shall fully and completely disclose any situation that may
present a conflict of interest. If the Contractor is now performing or elects to perform during the term of this contract any services for any AHCCCS health plan, provider or Contractor or an entity owning or controlling same, the Contractor shall
disclose this relationship prior to accepting any assignment involving such party. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

124 










			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  

 13. CONTINUATION OF PERFORMANCE THROUGH TERMINATION 

The Contractor shall continue to perform, in accordance with the requirements of the contract, up to the date of termination and as directed in the termination
notice. 
 14. CONTRACT 
 The contract between AHCCCS
and the Contractor shall consist of: 1) the Request for Proposal (RFP) including AHCCCS policies and procedures incorporated by reference as part of the RFP and 2) the proposal submitted by the Contractor in response to the RFP including any Best
and Final Offers. In the event of a conflict in language between the proposal (including any Best and Final Offers) and the RFP (including AHCCCS policies and procedures incorporated by reference), the provisions and requirements set forth and/or
referenced in the RFP(including AHCCCS policies and procedures incorporated by reference) shall govern. 
 The contract shall be construed according to the
laws of the State of Arizona. The State of Arizona is not obligated for the expenditures under the contract until funds have been encumbered. 
 15.
CONTRACT INTERPRETATION AND AMENDMENT 
 No Parol Evidence - This contract is intended by the parties as a final and complete expression of their
agreement. No course of prior dealings between the parties and no usage of the trade shall supplement or explain any term used in this contract. 
 No
Waiver - Either party’s failure to insist on strict performance of any term or condition of the contract shall not be deemed a waiver of that term or condition even if the party accepting or acquiescing in the non-conforming performance
knows of the nature of the performance and fails to object to it. 
 Written Contract Amendments - The contract shall be modified only through a
written contract amendment within the scope of the contract signed by the procurement officer on behalf of the State and signed by a duly authorized representative of the Contractor. 

16. COOPERATION WITH OTHER CONTRACTORS 
 AHCCCS may award
other contracts for additional work related to this contract and Contractor shall fully cooperate with such other contractors and AHCCCS employees or designated agents. The Contractor shall not commit or permit any act which will interfere with the
performance of work by any other Contractor or by AHCCCS employees. 
 17. COVENANT AGAINST CONTINGENT FEES 

The Contractor warrants that no person or agency has been employed or retained to solicit or secure this contract upon an agreement or understanding for a
commission, percentage, brokerage or contingent fee. For violation of this warranty, AHCCCS shall have the right to annul this contract without liability. 

18. DATA CERTIFICATION 
 The Contractor shall certify that
financial and encounter data submitted to AHCCCS is complete, accurate and truthful. Certification of financial and encounter data must be submitted concurrently with the data. Certification may be provided by the Contractor CEO, CFO or an
individual who is delegated authority to sign for, and who reports directly to the CEO or CFO [42 CFR 438.604 et seq.]. 
 19. DISPUTES 

Contract claims and disputes shall be adjudicated in accordance with State Law, AHCCCS Rules and this contract. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

125 










			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  

 Except as provided by 9 A.A.C. Chapter 22, Article 6, the exclusive manner for the Contractor to assert any
dispute against AHCCCS shall be in accordance with the process outlined in 9 A.A.C. Chapter 34 and A.R.S. §36-2932. All disputes except as provided under 9 A.A.C. Chapter 22, Article 6 shall be filed in writing and be received by AHCCCS no
later than 60 days from the date of the disputed notice. All disputes shall state the factual and legal basis for the dispute. Pending the final resolution of any disputes involving this contract, the Contractor shall proceed with performance of
this contract in accordance with AHCCCS’ instructions, unless AHCCCS specifically, in writing, requests termination or a temporary suspension of performance. 

20. E-VERIFY REQUIREMENTS 
 In accordance with A.R.S
§41-4401, the Contractor warrants compliance with all Federal immigration laws and regulations relating to employees and warrants its compliance with Section A.R.S. §23-214, Subsection A. 

21. EFFECTIVE DATE 
 The effective date of this contract
shall be the Offer and Acceptance date referenced on page 1 of this contract. 
 22. FEDERAL IMMIGRATION AND NATIONALITY ACT 

The Contractor shall comply with all Federal, State and local immigration laws and regulations relating to the immigration status of their employees during the
term of the contract. Further, the Contractor shall flow down this requirement to all subcontractors utilized during the term of the contract. The State shall retain the right to perform random audits of Contractor and subcontractor records or to
inspect papers of any employee thereof to ensure compliance. Should the State determine that the Contractor and/or any subcontractors be found noncompliant, the State may pursue all remedies allowed by law, including, but not limited to; suspension
of work, termination of the contract for default and suspension and/or debarment of the Contractor. 
 23. GRATUITIES 

AHCCCS may, by written notice to the Contractor, immediately terminate this contract if it determines that employment or a gratuity was offered or made by the
Contractor or a representative of the Contractor to any officer or employee of the State for the purpose of influencing the outcome of the procurement or securing the contract, an amendment to the contract, or favorable treatment concerning the
contract, including the making of any determination or decision about contract performance. AHCCCS, in addition to any other rights or remedies, shall be entitled to recover exemplary damages in the amount of three times the value of the gratuity
offered by the Contractor. 
 24. INCORPORATION BY REFERENCE 

This solicitation and all attachments and amendments, the Contractor’s proposal, best and final offer accepted by AHCCCS, and any approved subcontracts
are hereby incorporated by reference into the contract. 
 25. INDEMNIFICATION 

Contractor/Vendor Indemnification (Not Public Agency): 

The parties to this contract agree that the State of Arizona, its departments, agencies, boards and commissions shall be indemnified and held harmless by the
Contractor for the vicarious liability of the State as a result of entering into this contract. The Contractor agrees to indemnify, defend, and hold harmless the State from and against any and all claims, losses, liability, costs, and expenses,
including attorney’s fees and costs, arising out of litigation against AHCCCS including, but not limited to, class action lawsuits challenging actions by the Contractor. The requirement for indemnification applies irrespective of whether or not
the Contractor is a party to the lawsuit. Each Contractor shall indemnify the State, on a pro rata basis based on population, attorney’s fees and costs awarded against the State as well as the attorney’s fees and costs incurred by the
State in defending the lawsuit. The Contractor shall also indemnify AHCCCS, on a pro rata basis based on population, the administrative expenses incurred by AHCCCS to address Contractor deficiencies arising out of the litigation. The parties further
agree that the State of Arizona, its departments, agencies, boards and commissions shall be responsible for its own negligence and/or willful misconduct. Each party to this contract is responsible for its own negligence and/or willful misconduct.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

126 










			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  

 Contractor/Vendor Indemnification (Public Agency): 

Each party (“as indemnitor”) agrees to indemnify, defend, and hold harmless the other party (“as indemnitee”) from and against any and all
claims, losses, liability, costs, or expenses (including reasonable attorney’s fees) (hereinafter collectively referred to as ‘claims’) arising out of bodily injury of any person (including death) or property damage but only to the
extent that such claims which result in vicarious/derivative liability to the indemnitee, are caused by the act, omission, negligence, misconduct, or other fault of the indemnitor, its officers, officials, agents, employees, or volunteers. 

26. INDEMNIFICATION - PATENT AND COPYRIGHT 
 To the extent
permitted by applicable law the Contractor shall defend, indemnify and hold harmless the State against any liability including costs and expenses for infringement of any patent, trademark or copyright arising out of contract performance or use by
the State of materials furnished or work performed under this contract. The State shall reasonably notify the Contractor of any claim for which it may be liable under this paragraph. 

27. INSURANCE 
 The Contractor is required to maintain
insurance, at a minimum, as specified in Attachment E-1 Standard Professional Service Contracts. For policies for insurance for professional service contracts working with children or vulnerable adults, the policy may be endorsed to include coverage
for sexual abuse and molestation. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

127 










			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  

 ATTACHMENT E-1 

STANDARD PROFESSIONAL SERVICE CONTRACT 

INDEMNIFICATION CLAUSE: 
 To the fullest extent
permitted by law, Contractor shall defend, indemnify, save and hold harmless the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees (hereinafter referred to as
“Indemnitee”) from and against any and all claims, actions, liabilities, damages, losses, or expenses (including court costs, attorneys’ fees, and costs of claim processing, investigation and litigation) (hereinafter referred to as
“Claims”) for bodily injury or personal injury (including death), or loss or damage to tangible or intangible property caused, or alleged to be caused, in whole or in part, by the negligent or willful acts or omissions of Contractor or any
of its owners, officers, directors, agents, employees or subcontractors. This indemnity includes any claim or amount arising out of or recovered under the Workers’ Compensation Law or arising out of the failure of such Contractor to conform to
any Federal, State or local law, statute, ordinance, rule, regulation or court decree. It is the specific intention of the parties that the Indemnitee shall, in all instances, except for Claims arising solely from the negligent or willful acts or
omissions of the Indemnitee, be indemnified by Contractor from and against any and all claims. It is agreed that Contractor will be responsible for primary loss investigation, defense and judgment costs where this indemnification is applicable. In
consideration of the award of this contract, the Contractor agrees to waive all rights of subrogation against the State of Arizona, its officers, officials, agents and employees for losses arising from the work performed by the Contractor for the
State of Arizona. 
 This indemnity shall not apply if the Contractor or subcontractor(s) is/are an agency, board, commission or university of the State
of Arizona. 
 INSURANCE REQUIREMENTS: 

Contractors shall procure and maintain until all of their obligations have been discharged, including any warranty periods under this Contract, insurance
against claims for injury to persons or damage to property arising from or in connection with the performance of the work hereunder by the Contractor, its agents, representatives, employees or subcontractors. 

The insurance requirements herein are minimum requirements for this Contract and in no way limit the indemnity covenants contained in this Contract.
The State of Arizona in no way warrants that the minimum limits contained herein are sufficient to protect the Contractor from liabilities that arise out of the performance of the work under this contract by the Contractor, its agents,
representatives, employees or subcontractors, and the Contractor is free to purchase additional insurance. 
  

	A.	MINIMUM SCOPE AND LIMITS OF INSURANCE: Contractor shall provide coverage with limits of liability not less than those stated below. 


 

	 	1.	Commercial General Liability (CGL) – Occurrence Form 

 Policy shall
include bodily injury, property damage, and broad form contractual liability coverage. 
  

					
	 •    General Aggregate
	  	$	2,000,000	  
	 •    Products – Completed Operations Aggregate
	  	$	1,000,000	  
	 •    Personal and Advertising Injury
	  	$	1,000,000	  
	 •    Damage to Rented Premises
	  	$	50,000	  
	 •    Each Occurrence
	  	$	1,000,000	  

  

	 	a.	The policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as
additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

128 










			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  


	 	b.	Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials,
agents, and employees for losses arising from work performed by or on behalf of the Contractor. 

  

	 	2.	Business Automobile Liability 

 Bodily Injury and Property Damage for any owned, hired,
and/or non-owned vehicles used in the performance of this Contract. 
  

					
	 •    Combined Single Limit (CSL)
	  	$	1,000,000	  

  

	 	a.	Policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as
additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor, involving automobiles owned, leased, hired, and/or non-owned by the Contractor. 


 

	 	b.	Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials,
agents, and employees for losses arising from work performed by or on behalf of the Contractor. 

  

	 	c.	Policy shall contain a severability of interest provision. 

  

	 	3.	Worker’s Compensation and Employers’ Liability 

  

	 	•	 	Workers’ Compensation Statutory 

  

	 	•	 	Employers’ Liability 

  

					
	 Each Accident
	  	$	 500,000	  
	 Disease – Each Employee
	  	$	500,000	  
	 Disease – Policy Limit
	  	$	1,000,000	  

  

	 	a.	Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials,
agents, and employees for losses arising from work performed by or on behalf of the Contractor. 

  

	 	b.	This requirement shall not apply to each Contractor or subcontractor that is exempt under A.R.S. §23-901, and when such Contractor or subcontractor executes the appropriate waiver form (Sole Proprietor or
Independent Contractor). 

  

	 	4.	Professional Liability (Errors and Omissions Liability) 

  

					
	 Each Claim
	  	$	1,000,000	  
	 Annual Aggregate
	  	$	2,000,000	  

  

	 	a.	In the event that the Professional Liability insurance required by this Contract is written on a claims-made basis, Contractor warrants that any retroactive date under the policy shall precede the effective date of this
Contract; and either continuous coverage will be maintained or an extended discovery period will be exercised for a period of two (2) years beginning at the time work under this Contract is completed. 


 

	 	b.	The policy shall cover professional misconduct or negligent acts for those positions defined in the Scope of Work of this Contract. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

129 










			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  


	B.	ADDITIONAL INSURANCE REQUIREMENTS: The policies shall include, or be endorsed to include, as required by this written agreement, the following provisions: 


 

	 	1.	The Contractor’s policies shall stipulate that the insurance afforded the Contractor shall be primary and that any insurance carried by AHCCCS, its agents, officials, employees or the State of Arizona shall be
excess and not contributory insurance, as provided by A.R.S. §41-621 (E). 

  

	 	2.	Insurance provided by the Contractor shall not limit the Contractor’s liability assumed under the indemnification provisions of this Contract. 


 

	C.	NOTICE OF CANCELLATION: For each insurance policy required by the insurance provisions of this Contract, the Contractor must provide to the State of Arizona, within two (2) business days of receipt, a
notice if a policy is suspended, voided, or cancelled for any reason. Such notice shall be sent to AHCCCS Contracts Unit, Mail Drop 5700, Division of Business and Finance, 701 E. Jefferson St., Phoenix, AZ 85034. 


 

	D.	ACCEPTABILITY OF INSURERS: Contractor’s insurance shall be placed with companies licensed in the State of Arizona or hold approved non-admitted status on the Arizona Department of Insurance List of
Qualified Unauthorized Insurers. Insurers shall have an “A.M. Best” rating of not less than A- VII. The State of Arizona in no way warrants that the above-required minimum insurer rating is sufficient to protect the Contractor from
potential insurer insolvency. 

  

	E.	VERIFICATION OF COVERAGE: Contractor shall furnish the State of Arizona with certificates of insurance (valid ACORD form or equivalent approved by the State of Arizona) as required by this Contract and as
specified in Attachment F3, Contractor Chart of Deliverables. An authorized representative of the insurer shall sign the certificates.  


All certificates and endorsements, as required by this written agreement, are to be received and approved by the State of Arizona before work
commences. Each insurance policy required by this Contract must be in effect at or prior to commencement of work under this Contract. Failure to maintain the insurance policies as required by this Contract, or to provide evidence of renewal, is a
material breach of Contract. 
 All certificates required by this Contract shall be sent directly to AHCCCS Contracts Unit, Mail Drop 5700,
Division of Business and Finance, 701 E. Jefferson St., Phoenix, AZ 85034. All subcontractors are required to maintain insurance and to provide verification upon request. The AHCCCS project/contract number and project description shall be noted on
the certificate of insurance. The State of Arizona and AHCCCS reserves the right to require complete, certified copies of all insurance policies required by this Contract at any time. 

 

	F.	SUBCONTRACTORS: Contractors’ certificate(s) shall include all subcontractors as insureds under its policies or Contractor shall be responsible for ensuring and/or verifying that all subcontractors
have valid and collectable insurance as evidenced by the certificates of insurance and endorsements for each subcontractor. All coverages for subcontractors shall be subject to the minimum Insurance Requirements identified above. AHCCCS reserves the
right to require, at any time throughout the life of this contract, proof from the Contractor that its subcontractors have the required coverage. 

  

	G.	APPROVAL AND MODIFICATIONS: AHCCCS, in consultation with State Risk, reserves the right to review or make modifications to the insurance limits, required coverages, or endorsements throughout the life of
this contract, as deemed necessary. Such action will not require a formal contract amendment but may be made by administrative action. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

130 










			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  


	H.	EXCEPTIONS: In the event the Contractor or subcontractor(s) is/are a public entity, then the Insurance Requirements shall not apply. Such public entity shall provide a certificate of self-insurance. If the
Contractor or subcontractor(s) is/are a State of Arizona agency, board, commission, or university, none of the above shall apply. 

 [END OF
ATTACHMENT E-1] 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

131 










			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  

 28. IRS W9 FORM 

In order to receive payment under any resulting contract, the Contractor shall have a current IRS W9 Form on file with the State of Arizona. 

29. LOBBYING 
 No funds paid to the Contractor by AHCCCS,
or interest earned thereon, shall be used for the purpose of influencing or attempting to influence an officer or employee of any Federal or State agency, a member of the United States Congress or State Legislature, an officer or employee of a
member of the United States Congress or State Legislature in connection with awarding of any Federal or State contract, the making of any Federal or State grant, the making of any Federal or State loan, the entering into of any cooperative
agreement, and the extension, continuation, renewal, amendment or modification of any Federal or State contract, grant, loan, or cooperative agreement. The Contractor shall disclose if any funds paid to the Contractor by AHCCCS have been used or
will be used to influence the persons and entities indicated above and will assist AHCCCS in making such disclosures to CMS. 
 30. NO GUARANTEED
QUANTITIES 
 AHCCCS does not guarantee the Contractor any minimum or maximum quantity of services or goods to be provided under this contract. 

31. NON-DISCRIMINATION 
 In accordance with A.R.S.
§41-1461 et seq. and Executive Order 2009-09, the Contractor shall provide equal employment opportunities for all persons, regardless of race, color, religion, creed, sex, age, national origin, disability or political affiliation. The
Contractor shall comply with the Americans with Disabilities Act. 
 32. NON-EXCLUSIVE REMEDIES 

The rights and the remedies of AHCCCS under this contract are not exclusive. 

33. OFF-SHORE PERFORMANCE OF WORK PROHIBITED 
 Any
services that are described in the specifications or scope of work that directly serve the State of Arizona or its clients and involve access to secure or sensitive data or personal client data shall be performed within the defined territories of
the United States. Unless specifically stated otherwise in the specifications, this paragraph does not apply to indirect or “overhead” services, redundant back-up services or services that are incidental to the performance of the contract.
This provision applies to work performed by subcontractors at all tiers. 
 34. ORDER OF PRECEDENCE 

The parties to this contract shall be bound by all terms and conditions contained herein. For interpreting such terms and conditions the following sources
shall have precedence in descending order: The Constitution and laws of the United States and applicable Federal regulations; the terms of the CMS 1115 waiver for the State of Arizona; the Constitution and laws of Arizona, and applicable State
Rules; the terms of this contract which consists of the RFP, the proposal of the successful Offeror, and any Best and Final Offer including any attachments, executed amendments and modifications; and AHCCCS policies and procedures. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

132 










			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  

 35. OWNERSHIP OF INFORMATION AND DATA 

Materials, reports and other deliverables created under this contract are the sole property of AHCCCS. The Contractor is not entitled to any rights to those
materials and may not transfer any rights to anyone else. Except as necessary to carry out the requirements of this contract, as otherwise allowed under this contract, or as required by law, the Contractor shall not use or release data, information
or materials, reports, or deliverables derived from that data or information without the prior written consent of AHCCCS. Data, information and reports collected or prepared by the Contractor in the course of performing its duties and obligations
under this contract shall not be used by the Contractor for any independent project of the Contractor or publicized by the Contractor without the prior written permission of AHCCCS. Subject to applicable state and Federal laws and regulations,
AHCCCS shall have full and complete rights to reproduce, duplicate, disclose and otherwise use all such information. 
 At the termination of the contract,
the Contractor shall make available all such data to AHCCCS within 30 days following termination of the contract or such longer period as approved by AHCCCS, Office of the Director. For purposes of this subsection, the term “data” shall
not include member medical records. 
 Except as otherwise provided in this section, if any copyrightable or patentable material is developed by the
Contractor in the course of performance of this contract, the Federal government, AHCCCS and the State of Arizona shall have a royalty-free, nonexclusive, and irrevocable right to reproduce, publish, or
otherwise use, and to authorize others to use, the work for state or Federal government purposes. The Contractor shall additionally be subject to the applicable provisions of 45 CFR Part 74. 

36. RESERVED 
 37. RELATIONSHIP OF PARTIES 

The Contractor under this contract is an independent Contractor. Neither party to this contract shall be deemed to be the employee or agent of the other party
to the contract. 
 38. RIGHT OF OFFSET 
 AHCCCS shall
be entitled to offset against any sums due the Contractor any expenses or costs incurred by AHCCCS or damages assessed by AHCCCS concerning the Contractor’s non-conforming performance or failure to perform the contract, including but not
limited to expenses, costs and damages. 
 39. RIGHT TO ASSURANCE 

If AHCCCS, in good faith, has reason to believe that the Contractor does not intend to perform or is unable to continue to perform this contract, the
procurement officer may demand in writing that the Contractor give a written assurance of intent to perform. The demand shall be sent to the Contractor by certified mail, return receipt required. Failure by the Contractor to provide written
assurance within the number of days specified in the demand may, at the State’s option, be the basis for terminating the contract. 
 40. RIGHT TO
INSPECT PLANT OR PLACE OF BUSINESS 
 AHCCCS may, at reasonable times, inspect the part of the plant or place of business of the Contractor or
subcontractor that is related to the performance of this contract, in accordance with A.R.S. §41-2547. 

41. RESERVED 
 42. SEVERABILITY 

The provisions of this contract are severable. Any term or condition deemed illegal or invalid shall not affect any other term or condition of the contract.


  
 Acute Care Contract 

10/01/2015 Renewal 
  

133 










			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  

 43. SUSPENSION OR DEBARMENT 

The Contractor shall not employ, consult, subcontract or enter into any agreement for Title XIX services with any person or entity who is debarred, suspended
or otherwise excluded from Federal procurement activity or from participating in non-procurement activities under regulations issued under Executive Order 12549 [42 CFR 438.610(a)(b)] or under guidelines implementing Executive Order 12549. This
prohibition extends to any entity which employs, consults, subcontracts with or otherwise reimburses for services any person substantially involved in the management of another entity which is debarred, suspended or otherwise excluded from Federal
procurement activity. The Contractor is obligated to screen all employees and contractors to determine whether any of them have been excluded from participation in Federal health care programs. The Contractor can search the HHS-OIG website by the
names of any individuals. The database can be accessed at http://www.oig.hhs.gov/fraud/exclusions.asp. 
 The Contractor shall not retain as a director,
officer, partner or owner of 5% or more of the Contractor entity, any person, or affiliate of such a person, who is debarred, suspended or otherwise excluded from Federal procurement activity. 

AHCCCS may, by written notice to the Contractor, immediately terminate this contract if it determines that the Contractor has been debarred, suspended or
otherwise lawfully prohibited from participating in any public procurement activity. 
 44. TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR AND
TERMINATION 
 Temporary Management/Operation by AHCCCS: Pursuant to the Medicaid Managed Care Regulations, 42 CFR 438.700 et seq. and State Law
A.R.S. §36-2903, AHCCCS is authorized to impose temporary management for a Contractor under certain conditions. Under Federal law, temporary management may be imposed if AHCCCS determines that there is continued egregious behavior by the
Contractor, including but not limited to the following: substantial failure to provide medically necessary services the Contractor is required to provide; imposition on enrollees premiums or charges that exceed those permitted by AHCCCS,
discrimination among enrollees on the basis of health status or need for health care services; misrepresentation or falsification of information to AHCCCS or CMS; misrepresentation or falsification of information furnished to an enrollee or
provider; distribution of marketing materials that have not been approved by AHCCCS or that are false or misleading; or behavior contrary to any requirements of Sections 1903(m) or 1932 of the Social Security Act. Temporary management may also be
imposed if AHCCCS determines that there is substantial risk to enrollees’ health or that temporary management is necessary to ensure the health of enrollees while the Contractor is correcting the deficiencies noted above or until there is an
orderly transition or reorganization of the Contractor. Under Federal law, temporary management is mandatory if AHCCCS determines that the Contractor has repeatedly failed to meet substantive requirements in Sections 1903(m) or 1932 of the Social
Security Act. Pursuant to 42 CFR 438.706, AHCCCS shall not delay imposition of temporary management to provide a hearing before imposing this sanction. 

If AHCCCS undertakes direct operation of the Contractor, AHCCCS, through designees appointed by the Director, shall be vested with full and exclusive power of
management and control of the Contractor as necessary to ensure the uninterrupted care to persons and accomplish the orderly transition of persons to a new or existing Contractor, or until the Contractor corrects the contract performance failure to
the satisfaction of AHCCCS. AHCCCS shall have the power to employ any necessary assistants, to execute any instrument in the name of the Contractor, to commence, defend and conduct in its name any action or proceeding in which the Contractor may be
a party; such powers shall only apply with respect to activities occurring after AHCCCS undertakes direct operation of the Contractor in connection with this Section. 

All reasonable expenses of AHCCCS related to the direct operation of the Contractor, including attorney fees, cost of preliminary or other audits of the
Contractor and expenses related to the management of any office or other assets of the Contractor, shall be paid by the Contractor or withheld from payment due from AHCCCS to the Contractor. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

134 










			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  

 Termination: AHCCCS reserves the right to terminate this contract in whole or in part due to
the failure of the Contractor to comply with any term or condition of the contract, including, but not limited to, circumstances which present risk to member health or safety, and as authorized by the Balanced Budget Act of 1997 and 42 CFR 438.708.
If the Contractor is providing services under more than one contract with AHCCCS, AHCCCS may deem unsatisfactory performance under one contract to be cause to require the Contractor to provide assurance of performance under any and all other
contracts. In such situations, AHCCCS reserves the right to seek remedies under both actual and anticipatory breaches of contract if adequate assurance of performance is not received. The Contracting Officer shall mail written notice of the
termination and the reason(s) for it to the Contractor by certified mail, return receipt requested. Pursuant to the Balanced Budget Act of 1997 and 42 CFR 438.708, AHCCCS shall provide the Contractor with a pre-termination hearing before termination
of the contract. 
 Upon termination, all documents, data, and reports prepared by the Contractor under the contract shall become the property of and be
delivered to AHCCCS on demand. 
 AHCCCS may, upon termination of this contract, procure on terms and in the manner that it deems appropriate, materials or
services to replace those under this contract. The Contractor shall be liable for any excess costs incurred by AHCCCS in re-procuring the materials or services. 

45. TERM OF CONTRACT AND OPTION TO RENEW 
 The initial
term of this contract shall be for three (3) initial years, with two (2) one-year options to extend, not to exceed a total contracting period of five (5) years. The contract cycle is October 1 through September 30 with an
annual October 1 renewal. The terms and conditions of any such contract extension shall remain the same as the original contract, as amended. Any contract extension shall be through contract amendment, and shall be at the sole option of AHCCCS.

 If the Contractor has been awarded a contract in more than one GSA, each such contract will be considered separately renewable. AHCCCS may renew the
Contractor’s contract in one GSA, but not in another. In the event AHCCCS determines there are issues of noncompliance by the Contractor in one GSA, AHCCCS may request an enrollment cap for the Contractor’s contracts in all other GSAs.
Further, AHCCCS may require the Contractor to renew all currently awarded GSAs, or may terminate the contract if the Contractor does not agree to renew all currently awarded GSAs. 

When the Contracting Officer issues an amendment to extend the contract, the provisions of such extension will be deemed to have been accepted 30 days after
the date of mailing by the Contracting Officer, unless a different time period is specified by AHCCCS, even if the extension amendment has not been signed by the Contractor, unless within that time the Contractor notifies the Contracting Officer in
writing that it refuses to sign the extension amendment. Failure of an existing Contractor to accept an amendment (or renew) may result in immediate suspension/termination of member assignment. If the Contractor provides such notification, the
Contracting Officer will initiate contract termination proceedings. 
 If the Contractor chooses not to renew this contract, the Contractor may be liable
for certain costs associated with the transition of its members to a different Contractor. The Contractor is required to provide 180 days advance written notice to the Contracts and Purchasing Administrator of its intent not to renew the contract.
If the Contractor provides the Contracts and Purchasing Administrator written notice of its intent not to renew this contract at least 180 days before its expiration, this liability for transition costs may be waived by the Contracting Officer. 

46. TERMINATION - AVAILABILITY OF FUNDS 
 Funds are not
presently available for performance under this contract beyond the current fiscal year. No legal liability on the part of AHCCCS for any payment may arise under this contract until funds are made available for performance of this contract. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

135 










			
	SECTION E: CONTRACT TERMS AND CONDITIONS	 	Contract No. YH14-0001

  

 
  

 Notwithstanding any other provision in the Agreement, this Agreement may be terminated by Contractor, if, for
any reason, there are not sufficient appropriated and available monies for the purpose of maintaining this Agreement. In the event of such termination, the Contractor shall have no further obligation to AHCCCS. 

47. TERMINATION FOR CONFLICT OF INTEREST 
 AHCCCS may
cancel this contract without penalty or further obligation if any person significantly involved in initiating, negotiating, securing, drafting or creating the contract on behalf of AHCCCS is, or becomes at any time while the contract or any
extension of the contract is in effect, an employee of, or a consultant to, any other party to this contract with respect to the subject matter of the contract. The cancellation shall be effective when the Contractor receives written notice of the
cancellation unless the notice specifies a later time. 
 If the Contractor is a political subdivision of the State, it may also cancel this contract as
provided by A.R.S. §38-511. 
 48. TERMINATION FOR CONVENIENCE 

AHCCCS reserves the right to terminate the contract in whole or in part at any time for the convenience of the State without penalty or recourse. The
Contracting Officer shall give written notice by certified mail, of the termination at least 90 days before the effective date of the termination. Upon receipt of written notice, the Contractor shall stop all work, as directed in the notice, notify
all subcontractors of the effective date of the termination and minimize all further costs to the State. In the event of termination under this paragraph, all documents, data and reports prepared by the Contractor under the contract shall become the
property of and be delivered to AHCCCS. The Contractor shall be entitled to receive just and equitable compensation for work in progress, work completed and materials accepted before the effective date of the termination. 

49. THIRD PARTY ANTITRUST VIOLATIONS 
 The Contractor
assigns to the State any claim for overcharges resulting from antitrust violations to the extent that those violations concern materials or services supplied by third parties to the Contractor toward fulfillment of this contract. 

50. TYPE OF CONTRACT 
 Fixed-Price, stated as capitated
per member per month, except as otherwise provided. 
 51. WARRANTY OF SERVICES 

The Contractor warrants that all services provided under this contract will conform to the requirements stated herein. AHCCCS’ acceptance of services
provided by the Contractor shall not relieve the Contractor from its obligations under this warranty. In addition to its other remedies, AHCCCS may, at the Contractor’s expense, require prompt correction of any services failing to meet the
Contractor’s warranty herein. Services corrected by the Contractor shall be subject to all of the provisions of this contract in the manner and to the same extent as the services originally furnished. 

[END OF SECTION E] 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

136 









			
	SECTION F: ATTACHMENTS
	ATTACHMENT F1:	 	
	ENROLLEE GRIEVANCE SYSTEM STANDARDS	 	Contract No. YH14-0001

  

 
  

SECTION F: ATTACHMENTS 
 ATTACHMENT F1.
ENROLLEE GRIEVANCE SYSTEM STANDARDS 
 The Contractor shall have a written policy delineating its Grievance System which shall be in accordance with
applicable Federal and State laws, regulations and policies, including, but not limited to 42 CFR Part 438 Subpart F. The Contractor shall furnish Grievance System information to enrollees no later than 12 days after the Contractor receives notice
of the enrollment and annually thereafter. The Contractor shall also provide this information to all providers and subcontractors at the time of contract. Additionally, the Contractor shall provide written notification of any significant change in
this policy at least 30 days before the intended effective date of the change. 
 The written information provided to enrollees describing the Grievance
System including the grievance process, the appeals process, enrollee rights, the grievance system requirements and timeframes, shall be in each prevalent non-English language occurring within the Contractor’s service area and in an easily
understood language and format. Written documents, including but not limited to, the Notice of Action, the Notice of Extension of Notice of Action, the Notice of Appeal Resolution and Notice of Extension for Resolution, shall contain information in
the prevalent non-English language(s), prominently displayed in large bold print on the first page of the document, advising the enrollee that the written document is available in the prevalent non-English language(s) and in alternative formats
along with an explanation of how enrollees may obtain this written information in the prevalent non-English language(s) and alternative formats. However, if prior to issuing a document in English, the Contractor receives information orally or in
writing that the enrollee has a limited English proficiency in a prevalent non-English language, the Contractor shall translate the document in the applicable prevalent non-English language before providing it to the enrollee. The Contractor shall
also inform enrollees that oral interpretation services are available in any language. 
 For additional information regarding the enrollee Notice of Action
process, the Contractor should refer to ACOM Policy 414 and 42 CFR Part 438. Failure to comply with any of these provisions may result in an imposition of sanctions.  

At a minimum, the Contractor’s Grievance System Standards and Policy shall specify: 

 

	1.	That the Contractor shall maintain records of all grievances, appeals and requests for hearing. 

  

	2.	That the Contractor has a mechanism for tracking receipt, acknowledgement, investigation and resolution of grievances, appeals and requests for hearing within the required timeframes. 


 

	3.	Information explaining the grievance, appeal, and fair hearing procedures and timeframes. This information shall include a description of the circumstances when there is a right to a hearing, the method for obtaining a
hearing, the requirements which govern representation at the hearing, the right to file grievance and appeals and the requirements and timeframes for filing a grievance, appeal, or request for hearing. 


 

	4.	The availability of assistance in the filing process and the Contractor’s toll-free numbers that an enrollee can use to file a grievance or appeal by phone. 


 

	5.	That the Contractor shall acknowledge receipt of each grievance and appeal. For grievances, the Contractor is not required to acknowledge receipt of the Grievance in writing, however, if the enrollee requests written
acknowledgement, the acknowledgement must be made within five business days of receipt of the request. For Appeals, the Contractor shall acknowledge receipt of standard appeals in writing within five business days of receipt and within one business
day of receipt of expedited appeals. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

137 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F1:	 	
	ENROLLEE GRIEVANCE SYSTEM STANDARDS	 	Contract No. YH14-0001

  

 
  


	6.	That the Contractor shall permit both oral and written appeals and grievances and that oral inquiries appealing an action are treated as appeals. 


 

	7.	The definition of action [42 CFR 438.400(b)] and that an enrollee, or their designated representative, may file an appeal of an action taken by the Contractor. Actions include: 


 

	 	a.	Denial or limited authorization of a requested service, including the type or level of service; 

  

	 	b.	Reduction, suspension, or termination of a previously authorized service; 

  

	 	c.	Denial, in whole or in part, of payment for a service; 

  

	 	d.	Failure to provide services in a timely manner, as defined by the State; 

  

	 	e.	Failure to act within the timeframes provided in 42 CFR 438.408(b) required for standard and expedited resolution of appeals and standard disposition of grievances; or 


 

	 	f.	Denial of a rural enrollee’s request to obtain services outside the Contractor’s network under 42 CFR 438.52(b)(2)(ii), when the Contractor is the only Contractor in the rural area. 


 

	8.	The definition of appeal as the request for review of an action, as defined above [42 CFR 438.400(b)]. 

  

	9.	That the Contractor shall ensure that individuals who make decisions regarding grievances and appeals are individuals not involved in any previous level of review or decision making and that individuals who make
decisions regarding: 1) appeals of denials based on lack of medical necessity, 2) a grievance regarding denial of expedited resolution of an appeal or 3) grievances or appeals involving clinical issues are health care professionals as defined in 42
CFR 438.2 with the appropriate clinical expertise in treating the enrollee’s condition or disease. 

  

	9.	The definition of grievance as a member’s expression of dissatisfaction with any aspect of their care, other than the appeal of actions. There are no time limits for filing an enrollee grievance. 


 

	10.	That an enrollee must file a grievance with the Contractor and that the enrollee is not permitted to file a grievance directly with AHCCCS. 


 

	11.	That the Contractor must resolve each grievance within 10 business days of receipt, absent extraordinary circumstances. However, no grievances shall exceed 90 days for resolution. Contractor decisions on enrollee
grievances cannot be appealed. 

  

	12.	That the Contractor responds in writing, if an enrollee requests a written explanation of the resolution, and the response must be mailed within 10 business days of resolution of the grievance. 


 

	13.	That an enrollee shall be given 60 days from the date of the Contractor’s Notice of Action to file an appeal. 

  

	14.	Information explaining that a provider acting on behalf of an enrollee and with the enrollee’s written consent, may file an appeal. 


 

	15.	That the Contractor include, as parties to the appeal, the enrollee, the enrollee’s legal representative, or the legal representative of a deceased enrollee’s estate. 


 

	16.	That the Contractor must ensure that punitive action is not taken against a provider who either requests an expedited resolution or supports an enrollee’s appeal. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

138 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F1:	 	
	ENROLLEE GRIEVANCE SYSTEM STANDARDS	 	Contract No. YH14-0001

  

 
  


	17.	The resolution timeframes for standard appeals and expedited appeals may be extended up to 14 days if the enrollee requests the extension or if the Contractor establishes a need for additional information and that the
delay is in the enrollee’s interest. 

  

	18.	That if the Contractor extends the timeframe for resolution of an appeal when not requested by the enrollee, the Contractor shall provide the enrollee with written notice of the reason for the delay. 


 

	19.	The definition of a service authorization request as an enrollee’s request for the provision of a service [42 CFR 431.201]. 

  

	20.	The definition of a standard authorization request. For standard authorization decisions, the Contractor must provide a Notice of Action to the enrollee as expeditiously as the enrollee’s health condition requires,
but not later than 14 days following the receipt of the authorization request with a possible extension of up to 14 days if the enrollee or provider requests an extension or if the Contractor establishes a need for additional information and delay
is in the enrollee’s best interest [42 CFR 438.210(d)(1)]. The Notice of Action must comply with the advance notice requirements when there is a termination or reduction of a previously authorized service OR when there is a denial of an
authorization request and the physician asserts that the requested service/treatment is a necessary continuation of a previously authorized service. 

  

	21.	The definition of an expedited authorization request. For expedited authorization decisions, the Contractor must provide a Notice of Action to the enrollee as expeditiously as the enrollee’s health condition
requires, but not later than three business days following the receipt of the authorization request with a possible extension of up to 14 days if the enrollee or provider requests an extension or if the Contractor establishes a need for additional
information and delay is in the enrollee’s interest [42 CFR 438.210(d)(2)]. 

  

	22.	That the Notice of Action for a service authorization decision not made within the standard or expedited timeframes, whichever is applicable, will be made on the date that the timeframes expire. If the Contractor
extends the timeframe to make a standard or expedited authorization decision, the Contractor must give the enrollee written notice of the reason to extend the timeframe and inform the enrollee of the right to file a grievance if the enrollee
disagrees with the decision. The Contractor must issue and carry out its decision as expeditiously as the enrollee’s health condition requires and no later than the date the extension expires. 


 

	23.	That the Contractor shall notify the requesting provider of the decision to deny or reduce a service authorization request. The notice to the provider must be written. 


 

	24.	That the Contractor shall mail a Notice of Action: 1) at least 10 days before the date of a termination, suspension or reduction of previously authorized AHCCCS services, except as provided in (a)-(e) below; 2) at
least five days before the date of action in the case of suspected fraud; 3) at the time of any action affecting the claim when there has been a denial of payment for a service, in whole or in part; 4) within 14 days from receipt of a standard
service authorization request and within three business days from receipt of an expedited service authorization request, unless an extension is in effect. For service authorization decisions, the Contractor shall also ensure that the Notice of
Action provides the enrollee with advance notice and the right to request continued benefits for all terminations and reductions of a previously authorized service and for denials when the physician asserts that the requested service/treatment which
has been denied is a necessary continuation of a previously authorized service. As described below, the Contractor may elect to mail a Notice of Action no later than the date of action when: 


 

	 	a.	The Contractor receives notification of the death of an enrollee 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

139 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F1:	 	
	ENROLLEE GRIEVANCE SYSTEM STANDARDS	 	Contract No. YH14-0001

  

 
  


	 	b.	The enrollee signs a written statement requesting service termination or gives information requiring termination or reduction of services (which indicates understanding that the termination or reduction will be the
result of supplying that information) 

  

	 	c.	The enrollee is admitted to an institution where he is ineligible for further services 

  

	 	d.	The enrollee’s address is unknown and mail directed to the enrollee has no forwarding address 

  

	 	e.	The enrollee has been accepted for Medicaid in another local jurisdiction 

  

	25.	That the Notice of Action must explain: 1) the action the Contractor has taken or intends to take, 2) the reasons for the action, 3) the enrollee’s right to file an appeal with the Contractor, 4) the procedures for
exercising these rights, 5) circumstances when expedited resolution is available and how to request it and 6) the enrollee’s right to receive continued benefits pending resolution of the appeal, how to request continued benefits and the
circumstances under which the enrollee may be required to pay for the cost of these services. The Notice of Action shall comply with ACOM Policy 414. 

  

	26.	The definition of a standard appeal and that the Contractor shall resolve standard appeals no later than 30 days from the date of receipt of the appeal unless an extension is in effect. If a Notice of Appeal Resolution
is not completed when the timeframe expires, the member’s appeal shall be considered to be denied by the Contractor, and the member can file a request for hearing. 


 

	27.	The definition of an expedited appeal and that the Contractor shall resolve all expedited appeals no later than three business days from the date the Contractor receives the appeal (unless an extension is in effect)
where the Contractor determines (for a request from the enrollee), or the provider (in making the request on the enrollee’s behalf indicates) that the standard resolution timeframe could seriously jeopardize the enrollee’s life or health
or ability to attain, maintain or regain maximum function. The Contractor shall make reasonable efforts to provide oral notice to an enrollee regarding an expedited resolution appeal. If a Notice of Appeal Resolution is not completed when the
timeframe expires, the member’s appeal shall be considered to be denied by the Contractor, and the member can file a request for hearing. 

  

	28.	That if the Contractor denies a request for expedited resolution, it must transfer the appeal to the 30-day timeframe for a standard appeal. The Contractor must make reasonable efforts to give the enrollee prompt oral
notice and follow-up within two days with a written notice of the denial of expedited resolution. 

  

	29.	That benefits shall continue until a hearing decision is rendered if: 1) the enrollee files an appeal before the later of a) 10 days from the mailing of the Notice of Action or b) the intended date of the
Contractor’s action, 2) a) the appeal involves the termination, suspension, or reduction of a previously authorized course of treatment or b) the appeal involves a denial and the physician asserts that the requested service/treatment is a
necessary continuation of a previously authorized service, 3) the services were ordered by an authorized provider and 4) the enrollee requests a continuation of benefits. 


For purposes of this paragraph, benefits shall be continued based on the authorization which was in place prior to the denial, termination,
reduction, or suspension which has been appealed. 
  

	30.	That the Contractor continues extended benefits originally provided to the enrollee until any of the following occurs: 1) the enrollee withdraws the appeal, 2) the enrollee has not specifically requested continued
benefits pending a hearing decision within 10 days of the Contractor mailing of the appeal resolution notice, or 3) AHCCCS issues a state fair hearing decision adverse to the enrollee. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

140 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F1:	 	
	ENROLLEE GRIEVANCE SYSTEM STANDARDS	 	Contract No. YH14-0001

  

 
  


	31.	That for appeals, the Contractor provides the enrollee a reasonable opportunity to present evidence and allegations of fact or law in person and in writing and that the Contractor informs the enrollee of the limited
time available in cases involving expedited resolution. 

  

	32.	That for appeals, the Contractor provides the enrollee and his representative the opportunity before and during the appeals process to examine the enrollee’s case file including medical records and other documents
considered during the appeals process. 

  

	33.	That the Contractor shall provide written Notice of Appeal Resolution to the enrollee and the enrollee’s representative or the representative of the deceased enrollee’s estate which must contain: 1) the
results of the resolution process, including the legal citations or authorities supporting the determination, and the date it was completed, and 2) for appeals not resolved wholly in favor of enrollees: a) the enrollee’s right to request a
State fair hearing (including the requirement that the enrollee must file the request for a hearing in writing) no later than 30 days after the date the enrollee receives the Contractor’s notice of appeal resolution and how to do so, b) the
right to receive continued benefits pending the hearing and how to request continuation of benefits and c) information explaining that the enrollee may be held liable for the cost of benefits if the hearing decision upholds the Contractor.


  

	34.	That if the enrollee files a request for hearing the Contractor must ensure that the case file and all supporting documentation is received by the AHCCCS Office of Administrative Legal Services (OALS) as specified by
OALS. The file provided by the Contractor must contain a cover letter that includes: 

  

	 	a.	Enrollee’s name 

  

	 	b.	Enrollee’s AHCCCS I.D. number 

  

	 	c.	Enrollee’s address 

  

	 	d.	Enrollee’s phone number (if applicable) 

  

	 	e.	Date of receipt of the appeal 

  

	 	f.	Summary of the Contractor’s actions undertaken to resolve the appeal and summary of the appeal resolution 

  

	35.	The following material shall be included in the file sent by the Contractor: 

  

	 	a.	The Enrollee’s written request for hearing 

  

	 	b.	Copies of the entire appeal file which includes all supporting documentation including pertinent findings and medical records 

  

	 	c.	The Contractor’s Notice of Appeal Resolution 

  

	 	d.	Other information relevant to the resolution of the appeal 

  

	36.	That if the Contractor or the State fair hearing decision reverses a decision to deny, limit or delay services not furnished during the appeal or the pendency of the hearing process, the Contractor shall authorize or
provide the services promptly and as expeditiously as the enrollee’s health condition requires irrespective of whether the Contractor contests the decision. 

  


	37.	That if the Contractor or State fair hearing decision reverses a decision to deny authorization of services and the disputed services were received pending appeal, the Contractor shall pay for those services, as
specified in policy and/or regulation. 

  

	38.	 That if the Contractor or the Director’s Decision reverses a decision to deny, limit, or delay authorization of services, and the member received
the disputed services while the appeal was pending, the Contractor shall process a claim for payment from the provider in a manner consistent with the Contractor’s or Director’s Decision and applicable statutes, Rules, policies, and
contract terms. The provider shall have 90 days from the date of the reversed decision to submit a clean claim to the Contractor for payment. For 



  
 Acute Care Contract 

10/01/2015 Renewal 
  

141 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F1:	 	
	ENROLLEE GRIEVANCE SYSTEM STANDARDS	 	Contract No. YH14-0001

  

 
  


	 	
all claims submitted as a result of a reversed decision, the Contractor is prohibited from denying claims for un-timeliness if they are submitted within the 90 day timeframe. The Contractor is
also prohibited from denying claims submitted as a result of a reversed decision because the member failed to request continuation of services during the appeals/hearing process: a member’s failure to request continuation of services during the
appeals/hearing process is not a valid basis to deny the claim. 

  

	39.	That if the Contractor or State fair hearing decision upholds a decision to deny authorization of services and the disputed services were received pending appeal, the Contractor may recover the cost of those services
from the enrollee. 

 [END OF ATTACHMENT F1] 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

142 









			
	SECTION F: ATTACHMENTS
	ATTACHMENT F2 PROVIDER CLAIM DISPUTE STANDARDS	 	Contract No. YH14-0001

  

 
  

ATTACHMENT F2. PROVIDER CLAIM DISPUTE STANDARDS 

The Contractor shall have in place a written claim dispute policy for its subcontractors and non-contracted providers. The policy shall be in accordance with
applicable Federal and State laws, regulations and policies. Failure to comply with any of these provisions may result in the imposition of sanctions.  

The claim dispute policy shall include the following provisions: 
  

	 	1.	That the Provider Claim Dispute Policy shall stipulate that all claim disputes must be adjudicated in Arizona, including those claim disputes arising from claims processed by an Administrative Services Subcontractor.


  

	 	2.	That the Provider Claim Dispute Policy shall be provided to all subcontractors at the time of contract. For providers without a contract, the claim dispute policy may be mailed with a remittance advice, provided the
remittance is sent within 45 days of receipt of a claim. 

  

	 	3.	That the Provider Claim Dispute Policy must specify that all claim disputes challenging claim payments, denials or recoupments must be filed in writing with the Contractor no later than 12 months from the date of
service, 12 months after the date of eligibility posting or within 60 days after the payment, denial or recoupment of a timely claim submission, whichever is later. 


 

	 	4.	That the Provider Claim Dispute Policy must specify a physical local address in Arizona for the submission of all provider claim disputes and hearing requests. 


 

	 	5.	That specific individuals are appointed with authority to require corrective action and with requisite experience to administer the claim dispute process. 


 

	 	6.	That the Contractor shall develop and maintain a tracking log for all claim disputes containing sufficient information to identify the Complainant, date of receipt, nature of the claim dispute, resolution of the claim
dispute and the date of resolution. 

  

	 	7.	That claim disputes are acknowledged in writing and within five business days of receipt. 

  

	 	8.	Claim disputes are thoroughly investigated using the applicable statutory, regulatory, contractual and policy provisions, ensuring that relevant facts are obtained from all parties. 


 

	 	9.	All documentation received by the Contractor during the claim dispute process is dated upon receipt. 

  

	 	10.	Claim disputes are filed in a secure, designated area and are retained for five years following the Contractor’s decision, the AHCCCS decision, judicial appeal or close of the claim dispute, whichever is later,
unless otherwise provided by law. 

  

	 	11.	A copy of the Contractor’s Notice of Decision “Decision” shall be mailed to all parties no later than 30 days after the provider files a claim dispute with the Contractor, unless the provider and
Contractor agree to a longer period. The Decision must include and describe in detail, the following: 

  

	 	a.	The nature of the claim dispute. 

  

	 	b.	The specific factual and legal basis for the dispute, including but not limited to, an explanation of the specific facts that pertain to the claim dispute, the identification of the member name, pertinent dates of
service, dates and specific reasons for Contractor denial / payment of the claim, and whether or not the provider is a contracted provider. 


  
 Acute Care Contract 

10/01/2015 Renewal 
  

143 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F2 PROVIDER CLAIM DISPUTE STANDARDS	 	Contract No. YH14-0001

  

 
  


	 	c.	The reasons supporting the Contractor Decision, including an explanation of 1) how the Contractor applies the relevant and specific facts in the case to the relevant laws to support the Contractor’s decision and 2)
the applicable statutes, rules, contractual provisions, policies, and procedures, if applicable. Reference to general legal authorities alone is not acceptable. 

  

	 	d.	The Provider’s right to request a hearing by filing a written request to the Contractor no later than 30 days after the date the provider receives the Decision. 


 

	 	e.	If the claim dispute is overturned, in full or in part, the requirement that the Contractor shall reprocess and pay the claim(s) in a manner consistent with the decision within 15 business days of the date of the
Decision. 

  

	 	12.	If the provider files a written request for hearing, the Contractor must ensure that all supporting documentation is received by the AHCCCS Office of Administrative Legal Services (OALS), no later than five business
days from the date the Contractor receives the provider’s written hearing request. The file sent by the Contractor must contain a cover letter that includes: 


 

	 	a.	The provider’s name 

  

	 	b.	The provider’s address 

  

	 	c.	The member’s name and AHCCCS Identification Number 

  

	 	d.	The provider’s phone number (if applicable) 

  

	 	e.	The date that the claim dispute was received by the Contractor 

  

	 	f.	A summary of the actions undertaken by the Contractor to resolve the claim dispute and basis for the determination 


If the Contractor upholds a claim dispute and a request for hearing is subsequently filed, the Contractor must review the matter to determine
why the request for hearing was filed and resolve the matter when appropriate. 
  

	 	13.	The following material shall be included in the file sent by the Contractor: 

  

	 	a.	The written request for hearing filed by the provider 

  

	 	b.	Copies of the entire file which includes pertinent records; and the Decision 

  

	 	c.	Other information relevant to the Decision 

  

	 	14.	If the Contractor’s Decision regarding a claim dispute is reversed, in full or in part, through the appeal process, the Contractor shall reprocess and pay the claim(s) in a manner consistent with the Decision along
with any applicable interest within 15 business days of the date of the Decision. 

 If the Contractor or the State fair
hearing decision reverses a decision to deny, limit or delay services not furnished during the claim dispute or the pendency of the hearing process, the Contractor shall authorize or provide the services promptly and as expeditiously as the
enrollee’s health condition requires irrespective of whether the Contractor contests the decision. 
 [END OF ATTACHMENT F2] 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

144 









			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3 CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  

ATTACHMENT F3. CONTRACTOR CHART OF DELIVERABLES 

The following table is a summary of the periodic reporting requirements for the Contractor and is subject to change at any time during the term of the
contract. The table is presented for convenience only and should not be construed to limit the Contractor’s responsibilities in any manner. Content for all deliverables is subject to review. AHCCCS may assess sanctions if it is determined that
late, inaccurate or incomplete data is submitted. 
 The deliverables listed below are due by 5:00 PM on the due date indicated, if the due date falls on a
weekend or a State Holiday the due date is 5:00 PM on the next business day. 
 If a Contractor is in compliance with the contractual standards on the
deliverables below marked with an asterisk (*), for a period of three consecutive months, the Contractor may request to submit data on a quarterly basis. However, if the Contractor is non-compliant with any standard on the deliverable or AHCCCS has
concerns during the reporting quarter, the Contractor must immediately begin to submit on a monthly basis until three consecutive months of compliance are achieved. 

AHCCCS will assess the following sanctions on the deliverables listed below, under DHCM, Acute Care Operations, Clinical Quality Management and Medical
Management that are not received by 5:00 PM on the due date indicated, if the due date falls on a weekend or a State Holiday, sanctions will be assessed on deliverables not received by 5:00 PM on the next business day. 

 

					
	 Late Deliverables
	  	 	 
	 1st time “late” sanction/ 1-10 days:
	  	$	5,000	  
	 1st time “late” sanction/ 11-20 days:
	  	$	10,000	  
	 1st time “late” sanction/ over 21 days:
	  	$	15,000	  
	 2nd time “late” sanction/ 1-10 days:
	  	$	10,000	  
	 2nd time “late” sanction/ 11-20 days:
	  	$	20,000	  
	 2nd time “late” sanction/over 21 days:
	  	$	30,000	  
	 3rd time “late” sanction/ 1-10 days:
	  	$	20,000	  
	 3rd time “late” sanction/ 11-20 days:
	  	$	40,000	  
	 3rd time “late” sanction/over 21 days:
	  	$	60,000	  

 The sanctions outlined above are deliverable specific. For example, if the Contractor submits its claims dashboard five days
late in January, a $5,000 sanction will be assessed. The next month, if the Contractor submits its administrative measures five days late, it will be assessed a 1st time late sanction of $5,000.
However if the Contractor submits the claims dashboard five days late again in March AHCCCS will assess a 2nd time late sanction of $10,000. 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

145 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DBF CONTRACTS & PURCHASING	 	Ad Hoc	 	Certifications of Insurance	 	Within 10 days of notification of contract award and prior to commencement of any services under this contract.	 	Section E	 	Paragraph 27	 	N/A	 	DBF Contracts Manager	 	Email notification to AHCCCS Procurement and Contracts Manager
									
	DBF CONTRACTS & PURCHASING	 	Ad Hoc	 	Insurance Material Change	 	Within 30 days of event	 	Section E	 	Paragraph 27	 	N/A	 	DBF Contracts Manager	 	Email notification to AHCCCS Procurement and Contracts Manager
									
	DBF TPL UNIT	 	Ad Hoc	 	Third Party Liability Reporting	 	Within 10 days of discovery	 	Section D	 	Paragraph 58	 	AHCCCS Technical Interface Guidelines	 	AHCCCS TPL Administrator	 	FTP server with email notification
									
	DBF TPL UNIT	 	Ad Hoc	 	Total Plan Case Settlement Reporting via Monthly File	 	20th day of the month	 	Section D	 	Paragraph 58	 	ACOM Policy 434	 	AHCCCS TPL Management Analyst	 	Email, Fax, or mail submission
									
	DBF TPL UNIT	 	Ad Hoc	 	Total Plan Case Settlement Reporting via the Settlement Notification Form	 	Within 10 business days from the settlement date	 	Section D	 	Paragraph 58	 	 ACOM Policy 434
 Attachment A
	 	AHCCCS TPL Management Analyst	 	Email, Fax, or mail submission


  
 Acute Care Contract 

10/01/2015 Renewal 
  

146 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM CLINICAL QUALITY MANAGEMENT	 	Ad Hoc	 	Actions Reported to the NPDB or a Regulatory Board	 	Within one business day	 	Section D	 	Paragraph 23	 	AMPM Chapter 900	 	DHCM Clinical Quality Management Unit	 	FTP server, password protected with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Ad Hoc	 	Adverse Action Reporting (Including Limitations and Terminations)	 	Within one business day	 	Section D	 	Paragraph 23	 	AMPM Chapter 900	 	DHCM Clinical Quality Management Unit	 	FTP server, password protected with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Ad Hoc	 	Advise of Significant Incidents/Accidents Including Abuse, Neglect and Unexpected Death	 	Within 1 day of awareness	 	Section D	 	Paragraph 23	 	AMPM Chapter 900	 	DHCM Clinical Quality Management Unit	 	FTP server, password protected with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Ad Hoc	 	AHCCCS Certificate of Necessity for Pregnancy Termination & AHCCCS Verification of Diagnosis by Contractor for Pregnancy Termination Requests	 	30 days after the end of the month	 	Section D	 	Paragraph 23	 	AMPM Chapter 400	 	DHCM Clinical Quality Management Unit	 	FTP server, password protected with email notification to CQM Administrator


  
 Acute Care Contract 

10/01/2015 Renewal 
  

147 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM CLINICAL QUALITY MANAGEMENT	 	Ad Hoc	 	Communication of Adverse Action to Provider	 	Within one business day	 	Section D	 	Paragraph 23	 	AMPM Chapter 900	 	DHCM Clinical Quality Management Unit	 	FTP server, password protected with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Ad Hoc	 	Credentialing and Re-credentialing Denials	 	Within 1 business day	 	Section D	 	Paragraph 62	 	AMPM 950	 	DHCM Clinical Quality Management Unit	 	FTP server, password protected with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Ad Hoc	 	HCAC and OPPC	 	Upon identification by Contractor	 	Section D	 	Paragraph 23; Paragraph 24	 	AMPM Chapter 900; AMPM Chapter 1000	 	DHCM Clinical Quality Management Unit	 	FTP server, password protected with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Ad Hoc	 	Immunization Audit	 	As requested by AHCCCS	 	Section D	 	Paragraph 23	 	AMPM Chapter 400	 	DHCM Clinical Quality Management Unit	 	FTP server, password protected with email notification to CQM Administrator


  
 Acute Care Contract 

10/01/2015 Renewal 
  

148 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM CLINICAL QUALITY MANAGEMENT	 	Ad Hoc	 	Performance Improvement Project Reports – Baseline, Interim, Final, and Updates as Requested	 	Refer to AMPM	 	Section D	 	Paragraph 23	 	AMPM Chapter 900	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Ad Hoc	 	Physician Incentives: Contractor-Selected and/or Developed Pay for Performance Initiatives	 	Prior Approval Required	 	Section D	 	Paragraph 42	 	N/A	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Ad Hoc	 	Physician Incentives: Contractual Arrangements with Substantial Financial Risk	 	45 days prior to implementation of the contract	 	Section D	 	Paragraph 42	 	N/A	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Ad Hoc	 	Stillbirth Supplement Request	 	Immediately following procedure	 	Section D	 	Paragraph 23	 	AMPM Chapter 400	 	DHCM Clinical Quality Management Unit	 	FTP server, password protected with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Annually	 	Crisis Services Policy	 	15 days after the start of the contract year	 	Section D	 	Paragraph 12	 	N/A	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator


  
 Acute Care Contract 

10/01/2015 Renewal 
  

149 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM CLINICAL QUALITY MANAGEMENT	 	Annually	 	Dental Plan and Evaluation	 	December 15th	 	Section D	 	Paragraph 23	 	AMPM Chapter 400	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Annually	 	EPSDT Plan and Evaluation	 	December 15th	 	Section D	 	Paragraph 23	 	AMPM Chapter 400	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Annually	 	Maternity Care Plan and Evaluation	 	December 15th	 	Section D	 	Paragraph 23	 	AMPM Chapter 400	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Annually	 	Performance Improvement Project Baseline	 	December 15th	 	Section D	 	Paragraph 23	 	AMPM Chapter 900	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Annually	 	Performance Improvement Project Re-Measurement	 	December 15th	 	Section D	 	Paragraph 23	 	AMPM Chapter 900	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Annually	 	Quality Assessment/Performance Improvement Plan and Evaluation	 	December 15th	 	Section D	 	Paragraph 23	 	AMPM Chapter 900	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator


  
 Acute Care Contract 

10/01/2015 Renewal 
  

150 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM CLINICAL QUALITY MANAGEMENT	 	Monthly	 	Monthly Pregnancy Termination	 	30 days after the end of the month	 	Section D	 	Paragraph 23	 	AMPM Chapter 400	 	DHCM Clinical Quality Management Unit	 	FTP server, password protected with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Monthly	 	Sterilization Reporting	 	30 days after the end of the month	 	Section D	 	Paragraph 23	 	AMPM Chapter 400	 	DHCM Clinical Quality Management Unit	 	FTP server, password protected with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Quarterly	 	Credentialing Quarterly Report	 	30 days after the end of each quarter	 	Section D	 	Paragraph 23	 	AMPM Chapter 900	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Quarterly	 	EPSDT Improvement and Adult Quarterly Monitoring	 	15 days after the end of each quarter	 	Section D	 	Paragraph 23	 	AMPM Chapter 400	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Quarterly	 	Key Staff: Staff Primary and Back-Up Contact Information for Urgent Issue Resolution	 	30 days after the end of each quarter	 	Section D	 	Paragraph 16	 	N/A	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator


  
 Acute Care Contract 

10/01/2015 Renewal 
  

151 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM CLINICAL QUALITY MANAGEMENT	 	Quarterly	 	QM Quarterly	 	45 days after the end of each quarter	 	Section D	 	Paragraph 23	 	AMPM Chapter 900	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator
									
	DHCM CLINICAL QUALITY MANAGEMENT	 	Semi-Annually	 	Semi-Annual Report of Number of Pregnant Women who are HIV/AIDS Positive	 	30 days after the reporting periods of: [10/1 through 3/31] & [4/1 through 9/30]	 	Section D	 	Paragraph 10	 	AMPM Chapter 400	 	DHCM Clinical Quality Management Unit	 	FTP server with email notification to CQM Administrator
									
	DHCM DATA ANALYSIS AND RESEARCH	 	Ad Hoc	 	Corporate Compliance: CMS Compliance Issues Related to HIPAA Transaction and Code Set Complaints or Sanction	 	Immediately upon discovery	 	Section D	 	Paragraph 62	 	N/A	 	DHCM Encounter Administrator	 	Email notification
									
	DHCM DATA ANALYSIS AND RESEARCH	 	Ad Hoc	 	Medical Records or Supporting Documentation	 	As specified in the requesting letter	 	Section D	 	Paragraph 65	 	AHCCCS Data Validation User Manual	 	DHCM Encounter Administrator	 	FTP server
									
	DHCM DATA ANALYSIS AND RESEARCH	 	Annually	 	AHCCCS Security Rule Compliance Report	 	June 1st	 	Section D	 	Paragraph 64	 	ACOM Policy 108	 	DHCM Data Analysis and Research Manager	 	FTP server
									
	DHCM DATA ANALYSIS AND RESEARCH	 	Monthly	 	Corrected Pended Encounter Data	 	Monthly, according to established schedule	 	Section D	 	Paragraph 65	 	AHCCCS Encounter Manual	 	DHCM Encounter Administrator	 	FTP server


  
 Acute Care Contract 

10/01/2015 Renewal 
  

152 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM DATA ANALYSIS AND RESEARCH	 	Monthly	 	New Day Encounter	 	Monthly, according to established schedule	 	Section D	 	Paragraph 65	 	AHCCCS Encounter Manual	 	DHCM Encounter Administrator	 	FTP server
									
	DHCM DATA ANALYSIS AND RESEARCH	 	Quarterly	 	Encounter Submission and Tracking	 	15 days after the end of each quarter	 	Section D	 	Paragraph 65	 	AHCCCS Encounter Manual	 	DHCM Encounter Administrator	 	FTP server
									
	DHCM DATA ANALYSIS AND RESEARCH	 	Quarterly	 	Plan Overrides	 	15 days after the end of each quarter	 	Section D	 	Paragraph 65	 	AHCCCS Encounter Manual	 	DHCM Encounter Administrator	 	FTP server
									
	DHCM DATA ANALYSIS AND RESEARCH	 	Quarterly	 	Plan Voids	 	15 days after the end of each quarter	 	Section D	 	Paragraph 65	 	AHCCCS Encounter Manual	 	DHCM Encounter Administrator	 	FTP server
									
	DHCM FINANCE	 	Ad Hoc	 	Corporate Cost Allocation Plans and Adjustment in Management Fees	 	Prior approval required	 	Section D	 	Paragraph 43	 	N/A	 	DHCM Finance Manager	 	FTP server with email notification
									
	DHCM FINANCE	 	Ad Hoc	 	Equity Distributions	 	Submit for approval prior to effective date	 	Section D	 	Paragraph 49	 	N/A	 	DHCM Finance Manager	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

153 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM FINANCE	 	Ad Hoc	 	Health Insurer Fee: No fee due (if Annual Reporting Does Not Apply)	 	September 30th of each fee year	 	Section D	 	Paragraph 53	 	 ACOM Policy
 320
	 	DHCM Finance Manager	 	FTP server with email notification
									
	DHCM FINANCE	 	Ad Hoc	 	Merger, Acquisition, Reorganization, Joint Venture, and Change in Ownership: Automatic Clearing House (ACH) Vendor Authorization Form	 	45 days prior to the effective date and commencement of operations	 	Section D	 	Paragraph 52	 	ACOM Policy 317	 	DHCM Financial Consultant	 	FTP server with email notification
									
	DHCM FINANCE	 	Ad Hoc	 	Performance Bond or Bond Substitute	 	30 days after notification from AHCCCS of the amount required	 	Section D	 	Paragraph 46; Paragraph 47	 	ACOM Policy 305	 	DHCM Program Compliance Auditor	 	Secure email
									
	DHCM FINANCE	 	Annually	 	Annual Reconciliation to Draft Audit	 	90 days after year end	 	Section D	 	Paragraph 50	 	AHCCCS Financial Reporting Guide For Acute Care Contractors	 	DHCM Program Compliance Auditor	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

154 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM FINANCE	 	Annually	 	Annual Reconciliation to Final Audit	 	120 days after year end	 	Section D	 	Paragraph 50	 	AHCCCS Financial Reporting Guide For Acute Care Contractors	 	DHCM Program Compliance Auditor	 	FTP server with email notification
									
	DHCM FINANCE	 	Annually	 	Annual Related Party Transaction Statement	 	120 days after year end	 	Section D	 	Paragraph 50	 	AHCCCS Financial Reporting Guide For Acute Care Contractors	 	DHCM Program Compliance Auditor	 	FTP server with email notification
									
	DHCM FINANCE	 	Annually	 	Draft Annual Financial Reporting Package	 	90 days after the end of each fiscal year	 	Section D	 	Paragraph 50	 	AHCCCS Financial Reporting Guide For Acute Care Contractors	 	DHCM Program Compliance Auditor	 	FTP server with email notification
									
	DHCM FINANCE	 	Annually	 	Final Annual Financial Reporting Package	 	120 days after the end of each fiscal year	 	Section D	 	Paragraph 50	 	AHCCCS Financial Reporting Guide For Acute Care Contractors	 	DHCM Program Compliance Auditor	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

155 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM FINANCE	 	Annually	 	Final Management Letter	 	120 days after year end	 	Section D	 	Paragraph 50	 	AHCCCS Financial Reporting Guide For Acute Care Contractors	 	DHCM Program Compliance Auditor	 	FTP server with email notification
									
	DHCM FINANCE	 	Annually	 	Health Insurer Fee: Federal and State Income Tax Filings	 	April 30th of the year following the fee year	 	Section D	 	Paragraph 53	 	 ACOM Policy
 320
	 	DHCM Finance Manager	 	FTP server with email notification
									
	DHCM FINANCE	 	Annually	 	Health Insurer Fee: Liability Reporting Template	 	September 30th of each fee year	 	Section D	 	Paragraph 53	 	 ACOM Policy
 320
	 	DHCM Finance Manager	 	FTP server with email notification
									
	DHCM FINANCE	 	Annually	 	Health Insurer Fee: Report of Health Insurance Provider Information	 	September 30th of each fee year	 	Section D	 	Paragraph 53	 	ACOM Policy 320	 	DHCM Finance Manager	 	FTP server with email notification
									
	DHCM FINANCE	 	Annually	 	Value-Based Purchasing (VBP) Strategies Certification (Initial)	 	Within 60 days of the start of the measurement year	 	Section D	 	Paragraph 76	 	ACOM Policy 315 CYE 16	 	DHCM Finance Manager	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

156 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM FINANCE	 	Annually	 	Value-Based Purchasing (VBP) Strategies (Final)	 	Within 180 days of the end of the measurement year	 	Section D	 	Paragraph 76	 	ACOM Policy 315 CYE 16	 	DHCM Finance Manager	 	FTP server with email notification
									
	DHCM FINANCE	 	Quarterly	 	Cost Avoidance/Recovery	 	Due 45 days after the reporting quarter: (Oct—Dec: Due Feb 14) (Jan – March: Due May 15) (Apr – June: Due August 14) (July – Sept: Due Nov 14)	 	Section D	 	Paragraph 58	 	AHCCCS Program Integrity Reporting Guide	 	DHCM Program Compliance Auditor	 	FTP server with email notification
									
	DHCMFINANCE	 	Quarterly	 	FQHC Member Information	 	60 days after the end of each quarter	 	Section D	 	Paragraph 34	 	AHCCCS Financial Reporting Guide For Acute Care Contractors	 	DHCM Program Compliance Auditor	 	FTP server with email notification
									
	DHCM FINANCE	 	Quarterly	 	Premium Tax Reporting	 	March 15th, June 15th, September 15th, December 15th	 	Section D	 	Paragraph 67	 	ACOM Policy 304	 	DHCM Finance Program Monitor	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

157 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM FINANCE	 	Quarterly	 	Quarterly Financial Reporting Package	 	60 days after the end of each quarter	 	Section D	 	Paragraph 50	 	AHCCCS Financial Reporting Guide For Acute Care Contractors	 	DHCM Program Compliance Auditor	 	FTP server with email notification
									
	DHCM FINANCE	 	Quarterly	 	Verification of Receipt of Paid Services	 	15th day after the end of the quarter that follows the reporting quarter (Oct – Dec: Due April 15) (Jan – March: Due July 15) (April – June: Due Oct 15) (July – Sept: Due Jan 15)	 	Section D	 	Paragraph 19	 	ACOM Policy 424	 	DHCM Program Compliance Auditor	 	FTP server with email notification
									
	DHCM MEDICAL MANAGEMENT	 	Annually	 	HIV Specialty Provider List	 	December 15th	 	Section D	 	Paragraph 24	 	AMPM Chapter 1000	 	DHCM Medical Management Unit	 	FTP server with email notification
									
	DHCM MEDICAL MANAGEMENT	 	Annually	 	MM Plan, Evaluation and Work Plan	 	December 15th	 	Section D	 	Paragraph 24	 	AMPM Chapter 1000	 	DHCM Medical Management Unit	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

158 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM MEDICAL MANAGEMENT	 	Annually	 	Non-Transplant and Catastrophic Reinsurance	 	By October 30 of each contract year and when newly enrolled in the plan or newly diagnosed.	 	Section D	 	Paragraph 57	 	AMPM Chapter 1000; AHCCCS Reinsurance Policy Manual	 	DHCM Medical Management Unit	 	FTP server with email notification
									
	DHCM MEDICAL MANAGEMENT	 	Monthly	 	Hepatitis C Virus (HCV) Medication Report	 	10th day of the month	 	Section D	 	Paragraph 24	 	N/A	 	DHCM Medical Management Unit	 	FTP server with email notification
									
	DHCM MEDICAL MANAGEMENT	 	Quarterly	 	Quarterly Inpatient Hospital Showings	 	15 days after the end of each quarter	 	Section D	 	Paragraph 24	 	AMPM Chapter 1000	 	DHCM Medical Management Unit	 	FTP server with email notification
									
	DHCM MEDICAL MANAGEMENT	 	Quarterly	 	Transplant Report	 	15 days after the end of each quarter	 	Section D	 	Paragraph 24	 	AMPM Chapter 1000	 	DHCM Medical Management Unit	 	FTP server with email notification
									
	DHCM MEDICAL MANAGEMENT	 	Semi-Annually	 	High Need/High Cost Coordination Summary	 	 January 15
 and July 15
	 	Section D	 	Paragraph 24	 	AMPM Chapter 1000	 	DHCM Medical Management Unit	 	FTP server with email notification
									
	DHCM MEDICAL MANAGEMENT	 	Semi-Annually	 	Restrictions Report	 	April 15 and October 15	 	Section D	 	Paragraph 24	 	N/A	 	DHCM Medical Management Unit	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

159 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM OPERATIONS	 	Ad Hoc	 	Administrative Services Subcontractor Non-Compliance Reporting	 	Within 30 days of discovery	 	Section D	 	Paragraph 37	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Administrative Services Subcontracts	 	60 days prior to the beginning date of the subcontract	 	Section D	 	Paragraph 37	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	AHCCCS Required Survey Results	 	45 days after the completion	 	Section D	 	Paragraph 19	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Appointment Availability Review Methods	 	30 days prior to implementation of the proposed method	 	Section D	 	Paragraph 33	 	ACOM Policy 417	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Centers of Excellence	 	April 1, 2016	 	Section D	 	Paragraph 76	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Claim Recoupments >12 Months from Original Payment	 	Upon identification by Contractor	 	Section D	 	Paragraph 38	 	ACOM Policy 412	 	DHCM Operations and Compliance Officer	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

160 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM OPERATIONS	 	Ad Hoc	 	Completed Merger, Acquisition, Reorganization, Joint Venture, and Change in Ownership: Documents required after AHCCCS Approval	 	Within 120 days of the completed merger, acquisition, reorganization, joint venture, or change of ownership	 	Section D	 	Paragraph 52	 	ACOM Policy 317	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Data Processes for Recoupments	 	120 days from receipt of approval	 	Section D	 	Paragraph 38	 	ACOM Policy 412	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Final Survey Tool	 	90 days prior to the intended start	 	Section D	 	Paragraph 19	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	ID Cards requiring AHCCCS Approval	 	30 days prior to dissemination	 	Section D	 	Paragraph 7	 	ACOM Policy 433	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Independent Audits of Claims Payment/Health Information Systems	 	Upon request by AHCCCS	 	Section D	 	Paragraph 38	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

161 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM OPERATIONS	 	Ad Hoc	 	Key Staff: Key Position Change	 	Within 7 days of learning of resignation	 	Section D	 	Paragraph 16	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Key Staff: Notification of Moving Functions Out of State	 	60 days prior to proposed change	 	Section D	 	Paragraph 16	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Marketing Materials	 	30 days prior to dissemination	 	Section D	 	Paragraph 61	 	ACOM Policy 101	 	DHCM Marketing Committee	 	Email to: MarketingCommittee@azahcccs.gov
									
	DHCM OPERATIONS	 	Ad Hoc	 	Marketing Sponsorship Request	 	30 days prior to dissemination	 	Section D	 	Paragraph 61	 	ACOM Policy 101	 	DHCM Marketing Committee	 	Email to: MarketingCommittee@azahcccs.gov
									
	DHCM OPERATIONS	 	Ad Hoc	 	Material Change to Provider Network	 	60 days prior to expected implementation of the change	 	Section D	 	Paragraph 29	 	ACOM Policy 439	 	DHCM Operations and Compliance Officer	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

162 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM OPERATIONS	 	Ad Hoc	 	Material Change to Business Operations	 	60 days prior to expected implementation of the change	 	Section D	 	Paragraph 44	 	ACOM Policy 439	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Member Information Materials	 	30 days prior to release	 	Section D	 	Paragraph 18	 	ACOM Policy 404	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Non-AHCCCS Required Survey Notification and Results	 	Notification: 15 days prior to conducting the survey. Results: 45 days after the completion	 	Section D	 	Paragraph 19	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Proposed Merger, Acquisition, Reorganization, Joint Venture, and Change in Ownership: Notification	 	180 days prior to the effective date	 	Section D	 	Paragraph 52	 	ACOM Policy 317	 	DHCM Operations and Compliance Officer	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

163 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM OPERATIONS	 	Ad Hoc	 	Proposed Merger, Acquisition, Reorganization, Joint Venture, and Change in Ownership: Transition Plan Initial Documents	 	180 days prior to the effective date	 	Section D	 	Paragraph 52	 	ACOM Policy 317	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Proposed Merger, Acquisition, Reorganization, Joint Venture, and Change in Ownership: Transition Plan Final Documents	 	90 days prior to the effective date	 	Section D	 	Paragraph 52	 	ACOM Policy 317	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Provider Advances and Loans	 	10 days prior to disbursement of funds	 	Section D	 	Paragraph 49	 	ACOM Policy 418	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	Single Claim Recoupments >$50,000	 	30 days prior to initiating the recoupment, or earlier if the information is available	 	Section D	 	Paragraph 38	 	ACOM Policy 412	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Ad Hoc	 	System Change Plan	 	Six months prior to expected implementation	 	Section D	 	Paragraph 64	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

164 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM OPERATIONS	 	Ad Hoc	 	Unexpected Change to Provider Network	 	Within one business day	 	Section D	 	Paragraph 29	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Annually	 	Administrative Services Subcontractor Evaluation Report	 	Within 90 days of the start of the contract year	 	Section D	 	Paragraph 37	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Annually	 	Annual Website Certification	 	45 days after the start of the contract year	 	Section D	 	Paragraph 18	 	ACOM Policy 404	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Annually	 	Business Continuity and Recovery Plan Summary	 	15 days after the start of the contract year	 	Section D	 	Paragraph 73	 	ACOM Policy 104	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Annually	 	Cultural Competency Plan Assessment	 	45 days after the start of the contract year	 	Section D	 	Paragraph 20	 	ACOM Policy 405	 	DHCM Operations and Compliance Officer	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

165 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM OPERATIONS	 	Annually	 	Key Staff: Functional Organization Chart	 	15 days after the start of the contract year	 	Section D	 	Paragraph 16	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Annually	 	Key Staff: Listing of All Key Staff	 	15 days after the start of the contract year	 	Section D	 	Paragraph 16	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Annually	 	Key Staff: Organization Chart	 	15 days after the start of the contract year	 	Section D	 	Paragraph 16	 	N/A	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Annually	 	Marketing Attestation Statement	 	45 days after the start of the contract year	 	Section D	 	Paragraph 61	 	ACOM Policy 101	 	DHCM Marketing Committee	 	Email to: MarketingCommittee@azahcccs.gov


  
 Acute Care Contract 

10/01/2015 Renewal 
  

166 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM OPERATIONS	 	Annually	 	Member Handbook	 	August 1 and 30 days prior to any changes	 	Section D	 	Paragraph 18	 	ACOM Policy 404	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Annually	 	Member Handbook and Provider Directory Request for Approval to Forgo Issuing Hard Copy	 	60 calendar days in advance of the member notification	 	Section D	 	Paragraph 18	 	ACOM Policy 404	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Annually	 	Member Information Attestation Statement	 	45 days after the start of the contract year	 	Section D	 	Paragraph 18	 	ACOM Policy 404	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Annually	 	Provider Network Development and Management Plan	 	45 days after the start of the contract year	 	Section D	 	Paragraph 27	 	ACOM Policy 415	 	DHCM Operations and Compliance Officer	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

167 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM OPERATIONS	 	Annually	 	Social Networking Administrator (Name and Contact Information)	 	Within 90 days of the start of the contract year and within 30 days of any changes	 	Section D	 	Paragraph 18	 	ACOM Policy 425	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Annually	 	Social Networking Applications Listing with URLs	 	Within 90 days of the start of the contract year and within 30 days of any changes	 	Section D	 	Paragraph 18	 	ACOM Policy 425	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Annually	 	Social Networking Attestation	 	Within 90 days of the start of the contract year	 	Section D	 	Paragraph 18	 	ACOM Policy 425	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Monthly	 	*Claims Dashboard	 	15th day of the month following the reporting period	 	Section D  	 	Paragraph 38	 	AHCCCS Claims Dashboard Reporting Guide	 	DHCM Operations and Compliance Officer	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

168 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM OPERATIONS	 	Monthly	 	Grievance System Report	 	First day of the 2nd Month following the month Being Reported	 	Section D	 	Paragraph 26	 	AHCCCS Grievance System Reporting Guide	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Monthly	 	Marketing Activities Report	 	10th of the month for the previous months activities	 	Section D	 	Paragraph 61	 	ACOM Policy 101	 	DHCM Marketing Committee	 	Email to: MarketingCommittee@azahcccs.gov
									
	DHCM OPERATIONS	 	Quarterly	 	Minimum Network Requirements Verification Template	 	October 15, January 15, April 15, July 15	 	Section D	 	Paragraph 28	 	ACOM Policy 436	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Quarterly	 	Provider Affiliation Transmission	 	October 15, January 15, April 15, July 15	 	Section D	 	Paragraph 28	 	AHCCCS Provider Affiliation Transmission Manual	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Quarterly	 	Provider/Network Changes Due to Rates Report	 	15 days after the end of each quarter	 	Section D	 	Paragraph 29	 	ACOM Policy 415 Attachment D and Attachment E	 	DHCM Operations and Compliance Officer	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

169 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	DHCM OPERATIONS	 	Quarterly	 	Telephone Performance Measures	 	15th day of the month following the reporting quarter	 	Section D	 	Paragraph 25	 	ACOM Policy 435	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	DHCM OPERATIONS	 	Semi-Annually	 	Member Newsletter	 	30 days prior to intended publication date	 	Section D	 	Paragraph 18	 	ACOM Policy 404	 	DHCM Operations and Compliance Officer	 	FTP server with email notification
									
	OFFICE OF INSPECTOR GENERAL	 	Annually	 	Attestation of Disclosure Information: Ownership and Control and Persons Convicted of a Crime	 	15 days after the start of the contract year	 	Section D	 	Paragraph 62	 	ACOM Policy 103	 	Office of Inspector – Inspector General	 	FTP server with email notification
									
	OFFICE OF INSPECTOR GENERAL	 	Annually	 	Corporate Compliance Plan	 	15 days after the start of the contract year	 	Section D	 	Paragraph 62	 	ACOM Policy 103	 	Office of Inspector General	 	FTP server with email notification
									
	OFFICE OF INSPECTOR GENERAL	 	Ad Hoc	 	Exclusions Identified Regarding Persons Convicted of a Crime	 	Immediately upon identification	 	Section D	 	Paragraph 62	 	N/A	 	Office of Inspector—Inspector General	 	FTP server with email notification


  
 Acute Care Contract 

10/01/2015 Renewal 
  

170 










			
	SECTION F: ATTACHMENTS
	ATTACHMENT F3: CONTRACTOR CHART OF DELIVERABLES	 	Contract No. YH14-0001

  

 
  


																	
	 Area
	 	 Timeframe
	 	 Report
	 	 When Due
	 	 Contract

Section
	 	 Contract

Paragraph
	 	 Reference/

Policy
	 	 Send To
	 	 Submitted Via

	OFFICE OF INSPECTOR GENERAL	 	Ad Hoc	 	Merger, Acquisition, Reorganization, Joint Venture, and Change of Ownership: Disclosure of Ownership and Control and Disclosure of Information on Persons Convicted of a Crime Information	 	45 days prior to the effective date and commencement of operations	 	Section D	 	Paragraph 52	 	ACOM Policy 317	 	Office of Inspector – Inspector General	 	FTP server with email notification
									
	OFFICE OF INSPECTOR GENERAL	 	Ad Hoc	 	Report Alleged Fraud/ Waste/Abuse of the AHCCCS Program	 	Immediately upon identification	 	Section D	 	Paragraph 62	 	ACOM Policy 103	 	Office of Inspector General	 	As noted on reporting form
									
	OFFICE OF INSPECTOR GENERAL	 	Quarterly	 	Corporate Compliance: External Auditing Schedule	 	15 days after the end of each quarter	 	Section D	 	Paragraph 62	 	N/A	 	Office of Inspector General	 	FTP server with email notification
									
	OFFICE OF INSPECTOR GENERAL	 	Semi-Annually	 	Corporate Compliance: Audit Summary	 	April 15 and October 15	 	Section D	 	Paragraph 62	 	N/A	 	Office of Inspector General	 	FTP server with email notification

 [END OF ATTACHMENT F3] 
 [END OF
SECTION F] 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

171 









			
	 SECTION G:
 REPRESENTATIONS AND
CERTIFICATIONS OF OFFEROR
	  	Contract No. YH14-0001

  
  

SECTION G: RESERVED 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

172 









			
	SECTION H: INSTRUCTIONS TO OFFERORS	  	Contract No. YH14-0001

  
  

SECTION H: RESERVED 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

173 









			
	SECTION I: EXHIBITS	  	Contract No. YH14-0001

  
  

SECTION I: RESERVED 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

174 









			
	ENDNOTES	  	Contract No. YH14-0001

  
  

ENDNOTES 
 Effective March 1, 2015 via contract
amendment, the contract language associated with the endnotes below was incorporated into the contract pursuant to CMS contract Managed Care compliance requirements. 

 
 i 

ii 
 iii 

iv 
 v 

vi 
 vii 

viii 
 ix 

x 
 xi 

xii 
 xiii 

xiv 
 xv 

xvi 
 xvii 

xviii 
 xix 

xx 
 xxi 

xxii 
 xxiii 

xxiv 
 xxv 

xxvi 
 xxvii 

xxviii 
 xxix 

xxx 
 xxxi 

xxxii 
 xxxiii 

xxxiv 
 xxxv 

  
 Acute Care Contract 

10/01/2015 Renewal 
  

175